Prevalence of Obesity, Diabetes, Hypertension, Hypercholesterolemia, and Metabolic Syndrome in Over 50-Year-Olds in Sanlucar de Barrameda, Spain
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Document downloaded from https://www.revespcardiol.org/, day 10/06/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
ORIGINAL ARTICLES
Prevalence of Obesity, Diabetes, Hypertension,
Hypercholesterolemia, and Metabolic Syndrome
in Over 50-Year-Olds in Sanlucar de Barrameda, Spain
Alejandro López Suárez,a Javier Elvira González,a Manuel Beltrán Robles,a Michael Alwakil,b
Juan Manuel Saucedo,b Antonio Bascuñana Quirell,a Miguel A. Barón Ramos,a
and Fernando Fernández Palacínc
a
Servicio de Medicina Interna, Hospital Virgen del Camino, Sanlúcar de Barrameda, Cádiz, Spain
b
Servicio de Urgencias, Hospital Virgen del Camino, Sanlúcar de Barrameda, Cádiz, Spain
c
Estadística e I.O. Facultad de Ciencias del Mar y Ambientales, Universidad de Cádiz, Cádiz, Spain
Introduction and objectives. The Spanish province of Prevalencia de obesidad, diabetes,
Cadiz has some of the poorest socioeconomic conditions hipertensión, hipercolesterolemia y síndrome
and the highest cardiovascular morbidity and mortality metabólico en adultos mayores de 50 años
rates in the country. The aim of this study was to de Sanlúcar de Barrameda
investigate the prevalence of cardiovascular risk factors in
the adult population of the city of Sanlucar de Barrameda Introducción y objetivos. Cádiz es una de las provin-
in Cadiz. cias con los marcadores socioeconómicos más desfavo-
Methods. This cross-sectional population-based study rables y la mayor morbimortalidad cardiovascular de Es-
involved 858 randomly selected individuals aged 50-75 paña. Se estudia la prevalencia de los factores de riesgo
years. Age- and sex-adjusted prevalences of the main cardiovascular en la población adulta de Sanlúcar de Ba-
cardiovascular risk factors were obtained. rrameda.
Results. The mean age of the study population was 61.5 Métodos. Estudio poblacional con selección aleatoria
years and 53.6% were women. Overall, 46% of men and de una muestra representativa constituida por 858 indivi-
61.7% of women were illiterate; 23.7% and 7.9%, duos con edades entre 50 y 75 años. Descripción de la
respectively, were current smokers; 30.9% and 44.8% prevalencia de los factores de riesgo cardiovascular prin-
had a sedentary lifestyle; 54% and 55.9% were obese; cipales ajustada por edad y sexo.
29.4% and 26.1% had diabetes; 45% and 52.4% had Resultados. La media de edad de los pacientes era
hypertension; 40.9% and 45.1% had hypercholesterolemia; 61,5 años, con un 53,6% de mujeres. La prevalencia de
and 58.8% and 57% had metabolic syndrome as defined sujetos sin estudios en varones y mujeres fue del 46 y el
by NCEP/ATP-III criteria. The prevalence of all 61,7%; de tabaquismo activo, el 23,7 y el 7,9%; de se-
cardiovascular risk factors, except smoking, increased dentarismo, el 30,9 y el 44,8%; de obesidad, el 54 y el
with age. Significant inverse associations were observed 55,9%; de diabetes, el 29,4 y el 26,1%; de hipertensión,
between educational level and obesity in men and el 45 y el 52,4%; de hipercolesterolemia, el 40,9 y el
between educational level and diabetes and metabolic 45,1%, y de síndrome metabólico (NCEP/ATP-III), el 58,8
syndrome in women. y el 57%. Con excepción del tabaquismo, la prevalencia
Conclusions. The prevalence of cardiovascular risk de todos los factores de riesgo aumentó con la edad. Se
factors in individuals aged 50-75 years in Sanlucar de aprecia una asociación significativa e inversa del nivel de
Barrameda was extremely high. The prevalences of estudios con la obesidad en varones, y con la diabetes y
obesity, diabetes, and metabolic syndrome were among el síndrome metabólico en mujeres.
the highest ever reported in Spain. A very low educational Conclusiones. La prevalencia de los factores de ries-
level may underlie these adverse findings. go cardiovascular en adultos de 50 a 75 años de Sanlú-
car de Barrameda es extraordinariamente elevada. Las
Key words: Obesity. Diabetes. Hypertension. prevalencias de obesidad, diabetes y síndrome metabóli-
Hypercholesterolemia. Metabolic syndrome. co se encuentran entre las más elevadas de las que se
ha comunicado hasta el momento en España. Un nivel de
estudios muy bajo puede estar en relación con un perfil
de riesgo tan elevado.
The researchers involved in the Sanlucar Study are given at the end.
Palabras clave: Obesidad. Diabetes. Hipertensión. Hi-
The Fundación Doctor Pascual financed the study with a collaborative percolesterolemia. Síndrome metabólico.
grant.
Correspondence: Dr. A. López Suárez.
Servicio de Medicina Interna. Hospital Virgen del Camino.
Ctra. de Chipiona, km 0.6. 11540 Sanlúcar de Barrameda. Cádiz. España.
E-mail: a.lopez.ssl@gmail.com
Received January 10, 2008.
Accepted for publication June 16, 2008.
1150 Rev Esp Cardiol. 2008;61(11):1150-8Document downloaded from https://www.revespcardiol.org/, day 10/06/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
López Suárez A et al. Prevalence of Cardiovascular Risk Factors in Over 50-Year-Olds. Sanlucar Study
syndrome as an independent cardiovascular risk factor
ABBREVIATIONS
in the development of atherosclerotic events, comparing
ABPM: ambulatory blood pressure monitoring 2 cohorts of individuals with and without the metabolic
BMI: body mass index syndrome after a follow-up of 5 years, this work still in
DBP: diastolic blood pressure progress. The Sanlucar Study was carried out by the
SBP: systolic blood pressure Internal Medicine Service of the Hospital Virgen del
SMBP: self-monitored blood pressure Camino of Sanlucar de Barrameda (Cadiz), and
commenced in July 2006. The current analysis was
performed after finalizing the inclusion period in February
2007. Thus, it is a cross-sectional, descriptive, population-
based study to establish the prevalence of cardiovascular
risk factors in the adult population of the city of Sanlucar
INTRODUCTION de Barrameda.
Cardiovascular disease continues to be the leading
Study Population and Calculation
cause of morbidity and mortality among adults in Spain.
of Sample Size
It is estimated that new coronary and cerebrovascular
events occur at a rate of 250-450 per 100 000 individuals Sanlucar de Barrameda is a coastal city of the province
per year.1 The distribution of mortality due to of Cadiz with a census population in 2005 of 63 509
cardiovascular disease is not uniform throughout Spain residents, almost all Caucasian. The target population
and an accentuated north-south gradient has been was made up of individuals between the ages of 50 and
confirmed. Three provinces of the Andalusian community 75 years and registered in the municipality. This list,
(Cadiz, Huelva, and Seville) carry one third of the excess provided by the city hall in December 2005, included a
all-cause mortality in the whole of Spain,2 despite total of 14 018 residents. After taking a random sample
comprising only 8% of the Spanish population. The of this population, one person was appointed to contact
highest mortality rates due to ischemic heart disease are the selected individuals by telephone to invite them to
also concentrated in the south, in the Canary Islands and participate in the study. Those who accepted were included
in Cadiz, Malaga, and Seville.3 Geographic differences after an interview by the physician investigator in the
related to socioeconomic and educational levels, the outpatient unit of the hospital and after obtaining informed
prevalence of cardiovascular risk factors and, to a lesser consent. All individuals were given a clinical report with
extent nowadays, the quality and accessibility of health the results of the physical examination and the laboratory
care are factors that may explain this asymmetry. tests.
Detailed and current knowledge of these variables is The sample size of the Sanlucar Study was calculated
essential in order to plan prevention and intervention using the age-adjusted annual incidence rate of coronary
policies for at-risk groups. Over recent years, numerous and cerebrovascular disease described in Spain,1 and an
cross-sectional studies and meta-analyses have been estimation of the relative risk of cardiovascular events
performed that have provided general information on the attributable to the metabolic syndrome.5,6 An incidence
prevalence of cardiovascular risk factors in different rate of cardiovascular events in the population aged over
geographical areas.4 Unfortunately, generation of this 50 years of 2.8% was selected, and the relative risk
information is neither stable nor updated and lacks data attributable to the metabolic syndrome was 2.75%.
from specific areas where the cardiovascular morbidity Determining a confidence interval of 95% and a
and mortality impact is very high. statistical power of 80%, a sample size of 760 cases was
We present the results of a population-based study calculated, which was increased by 10% to cover losses.
whose aim was to investigate the prevalence of the main
cardiovascular risk factors in the adult population of the
Inclusion and Exclusion Criteria
city of Sanlucar de Barrameda, Cadiz, Spain.
The individuals selected had to meet the following
inclusion criteria: resident in Sanlucar de Barrameda and
METHODS
be listed on the municipal census, be between 50 and 75
years of age, and provide informed consent. Persons
The Sanlucar Study
diagnosed with severe, life-threatening diseases were
The Sanlucar Study is a population-based prospective excluded. Other exclusion criteria were: documented
study designed with a 2-fold objective: to establish the diagnosis of malignant neoplasia; creatinine clearance
prevalence of the main cardiovascular risk factors in theDocument downloaded from https://www.revespcardiol.org/, day 10/06/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
López Suárez A et al. Prevalence of Cardiovascular Risk Factors in Over 50-Year-Olds. Sanlucar Study
Clinical and Laboratory Data Collection of the 24 h readings. The body mass index (BMI) was
Protocol calculated by dividing the weight (in kilos) by the square
of the height (in meters). The waist circumference was
The following variables were recorded: age, sex, measured using a semi-rigid measuring tape, with the
education level (4 categories: no schooling, primary individual in decubitus, at the point midway between
education, vocational training or secondary education, the last rib and the upper border of the iliac crest. Obesity
and university studies); smoking (current smoker— was considered to be a BMI ≥30 and overweight, a BMI
smokers at inclusion and ex-smokers for less than 1 year, ≥27. In individuals with undiagnosed diabetes, a new
and non-smoker—those who had never smoked and ex- diagnosis of diabetes was considered to be a plasma
smokers for more than 1 year); alcohol consumption glucose >126 mg/dL and elevated fasting plasma
(non-drinkers, drinkers of 1 or 2 units per day, and drinkers glucose, a blood glucose >100 and 190 hypercholesterolemia. For the diagnosis of the metabolic
mg/dL or receiving treatment with statins) or receiving syndrome the modified NCEP/ATP-III definition was
treatment for these conditions, and a first degree family used.11
history of early cardiovascular disease (men under 55
years and women under 65 years).
Statistical Analysis
After an overnight fast, venous blood samples were
taken to determine plasma levels of: glucose (enzymatic The normality of the quantitative variables was
oxidation), creatinine (spectrophotometry), total confirmed using the Kolmogorov-Smirnov test. For the
cholesterol (enzymatic hydrolysis, colorimetry), high- description of the continuous variables the mean (standard
density lipoprotein cholesterol (HDL-C) (beta lipoprotein deviation), or the median in the case of non-normal
specific antibodies, spectrophotometry), triglycerides distribution, was used. The quantitative variables with a
(enzymatic hydrolysis, colorimetry), and uric acid non-normal distribution were transformed into their
(enzymatic oxidation), using an ILAB-600 analyzer. respective natural logarithms. The qualitative variables
The LDL-C was calculated using the Friedewald are expressed as a proportion and 95% confidence interval.
formula.10 For the bivariate analysis of parametric variables the
Blood pressure was measured with an OMRON difference of means test (Student t test) was used and for
705CP automatic blood pressure monitor, using an arm comparison of proportions the χ2 test. Logistic regression
cuff with a 12×40 cm bladder in obese patients with an analysis with the variable to be analyzed was performed
arm circumference >35 cm. Blood pressure was to assess, from the odds ratio (OR), the relationship
measured in the outpatient office during the course of between educational level and each of the cardiovascular
a clinical interview after the participant had been seated risk factors, differentiating by sex. In all cases the variables
for 5 min. The systolic blood pressure (SBP) and smoking, alcohol, a sedentary lifestyle, and age were
diastolic blood pressure (DBP) recorded were the mean included as control variables, in order to consider their
of 3 consecutive readings with a difference in the SBP potential confounding effect. For this analysis, the
140/90 mm Hg were offered confirmation via self- primary education, secondary education, vocational
monitored blood pressure (SMBP) if the clinical SBP training, and university studies). A P value less than .05
was 140-149 mm Hg or ambulatory blood pressure was considered significant. The analysis were performed
monitoring (ABPM) if the clinical SBP was >150 with SPSS, version 11.0.
mm Hg. For the SMBP the individuals were instructed
to perform 3 readings daily (before the 3 main meals
RESULTS
and after resting, seated at the table, for at least 5 min)
on 5 consecutive days, to obtain a total of 15 readings. From July 2006 until February 2007, 1174 individuals
Representative SBP and DBP values were the mean of were invited to participate in the study; 273 (23.2%)
13 readings, after excluding the first and last readings. refused to participate, 37 (3.1%) were excluded (19 for
The 24 hour ABPM was carried out with a BR-102 malignant neoplasms, 7 for neurodegenerative disease,
blood pressure recorder (Schiller AG, Baar, Switzerland), 4 for chronic heart failure, 4 for chronic respiratory
taking daytime readings every 20 min until 22:00 and insufficiency, 4 for advanced chronic renal failure, 3 for
night-time readings every 30 min until 7:00. cirrhosis, and 3 for connective tissue disorders) and 6
Representative values for SBP and DBP were the means were not located. The total number of valid cases finally
1152 Rev Esp Cardiol. 2008;61(11):1150-8Document downloaded from https://www.revespcardiol.org/, day 10/06/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
López Suárez A et al. Prevalence of Cardiovascular Risk Factors in Over 50-Year-Olds. Sanlucar Study
TABLE 1. Characteristics of the Sample
Total Men Women P
Patients, n (%) 858 398 (46.4) 460 (53.6)
Age, mean (SD), y 61.5 (6.8) 61.9 (6.8) 61.1 (6.7) NS
Educational level
No schooling 54.5 (51.1-57.9) 46 (41-51) 61.7 (57.1-66.2)Document downloaded from https://www.revespcardiol.org/, day 10/06/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
López Suárez A et al. Prevalence of Cardiovascular Risk Factors in Over 50-Year-Olds. Sanlucar Study
TABLE 2. Biochemical Parameters and Blood Pressure by Sex
Total Men Women P
Patients, n (%) 858 398 (46.4) 460 (53.6)
Waist circumference, cm 104.4 (12.5) 108.2 (11.1) 101.1 (12.7)Document downloaded from https://www.revespcardiol.org/, day 10/06/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
López Suárez A et al. Prevalence of Cardiovascular Risk Factors in Over 50-Year-Olds. Sanlucar Study
TABLE 4. Prevalence of Cardiovascular Risk Factors According to Level of Education
No Schooling Some Studies P
Patients, n (%) 468 (54.5) 390 (45.5)
Age, mean (SD), y 62.6 (6.6) 60 (6.7) 88 cm. Among those with a BMIDocument downloaded from https://www.revespcardiol.org/, day 10/06/2022. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
López Suárez A et al. Prevalence of Cardiovascular Risk Factors in Over 50-Year-Olds. Sanlucar Study
TABLE 5. Odds Ratio (95% Confidence Interval) for the Risk Factors According to Level of Education (Individuals
With no Schooling vs Individuals With Some Studies)
Obesity Diabetes Hypertension Hypercholesterolemia Metabolic Syndrome
Men
Unadjusted 1.5 (1-2.24)a 1.2 (0.78-1.84) 1.1 (0.74-1.64) 0.81 (0.54-1.22) 1.06 (0.71-1.58)
Smoking 1.55 (1.03-2.32)a 1.11 (0.72-1.72) 1.08 (0.72-1.62) 0.85 (0.57-1.28) 1.08 (0.72-1.62)
Alcohol 1.55 (1.04-2.33)a 1.16 (0.75-1.79) 1.1 (0.73-1.64) 0.84 (0.56-1.27) 1.09 (0.73-1.64)
Sedentary lifestyle 1.51 (1-2.45)a 1.2 (0.78-1.86) 1.1 (0.74-1.65) 0.81 (0.54-1.22) 1.06 (0.71-1.59)
Age 1.45 (0.96-2.17) 1.1 (0.71-1.72) 0.96 (0.64-1.45) 0.81 (0.54-1.22) 0.95 (0.63-1.44)
All 1.47 (0.97-2.24) 1.03 (0.65-1.61) 0.94 (0.61-1.43) 0.85 (0.56-1.3) 0.95 (0.62-1.45)
Women
Unadjusted 1.18 (0.81-1.72) 1.96 (1.24-3.09)b 1.35 (0.93-1.97) 1.43 (0.98-2.09) 1.71 (1.17-2.5)b
Smoking 1.11 (0.76-1.63) 1.86 (1.18-2.95)b 1.3 (0.89-1.91) 1.42 (0.97-2.09) 1.62 (1.11-2.39)a
Alcohol 1.2 (0.81-1.74) 2 (1.27-3.16)b 1.33 (0.91-1.94) 1.43 (0.97-2.09) 1.7 (1.16-2.49)b
Sedentary lifestyle 1.13 (0.77-1.67) 1.92 (1.22-3.04)b 1.32 (0.9-1.93) 1.42 (0.97-2.08) 1.67 (1.13-2.47)b
Age 1.07 (0.72-1.57) 1.65 (1.03-2.64)a 1.07 (0.72-1.59) 1.25 (0.84-1.85) 1.45 (0.98-2.15)
All 1.03 (0.69-1.55) 1.62 (1.01-2.62)a 1.02 (0.67-1.53) 1.23 (0.83-1.83) 1.4 (0.93-2.1)
a
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López Suárez A et al. Prevalence of Cardiovascular Risk Factors in Over 50-Year-Olds. Sanlucar Study
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