Original Article

Association Between Multiple Modifiable Risk Factors of Cardiovascular Disease and Hypertension among Asymptomatic Patients in Central Appalachia

Authors: Hadii M. Mamudu, PhD, MPA, Timir K. Paul, MD, PhD, Liang Wang, MD, DrPH, Sreenivas P. Veeranki, MBBS, DrPH, Hemang B. Panchal, MD, MPH, Arsham Alamian, MSc, PhD, Matthew Budoff, MD


Objectives: The central Appalachian region of the United States is disproportionately burdened with cardiovascular diseases (CVD) and associated risk factors; however, research to inform clinical practice and policies and programs is sparse. This study aimed to examine the association between multiple modifiable risk factors for CVD and hypertension in asymptomatic patients in central Appalachia.

Methods: Between January 2011 and December 2012, 1629 asymptomatic individuals from central Appalachia participated in screening for subclinical atherosclerosis. Participants were asked to report their hypertension status (yes/no). In addition, data on two nonmodifiable risk factors (sex, age) and five modifiable risk factors (obesity, diabetes mellitus, hypercholesterolemia, smoking, and sedentary lifestyle) were collected. Multivariable logistic regression analyses were conducted to assess association between hypertension and risk factors.

Results: Of the 1629 participants, approximately half (49.8%) had hypertension. Among people with hypertension, 31.4% were obese and 62.3% had hypercholesterolemia. After adjusting for sex and age, obesity and diabetes mellitus were associated with a more than twofold increased odds of having hypertension (odds ratio [OR] 2.02, confidence interval [CI] 1.57–2.60 and OR 2.30, CI 1.66–3.18, respectively). Hypercholesterolemia and sedentary lifestyle were associated with higher odds for hypertension (OR 1.26, CI 1.02–1.56 and OR 1.38, CI 1.12–1.70, respectively), compared with referent groups. Having two, three, and four to five modifiable risk factors was associated with increased odds of having hypertension by about twofold (OR 1.72, CI 1.21–2.44), 2.5-fold (OR 2.55, CI 1.74–3.74), and sixfold (OR 5.96, CI 3.42–10.41), respectively.

Conclusions: This study suggests that the odds of having hypertension increases with a higher number of modifiable risk factors for CVD. As such, implementing an integrated CVD program for treating and controlling modifiable risk factors for hypertension would likely decrease the future risk of CVD.

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1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2015 update: a report from the American Heart Association. Circulation 2015;131:e29-e322.
2. World Health Organization. A global brief on hypertension: silent killer, global health crisis. World Health Day 2013. http://apps.who.int/iris/bitstream/10665/79059/1/WHO_DCO_WHD_2013.2_eng.pdf?ua=1. Accessed December 22, 2015.
3. Institute of Medicine. A Population-Based and Systems Change Approach to Prevent and Control Hypertension. Washington, DC:The National Academies Press; 2010.
4. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
5. Nwankwo T, Yoon SS, Burt V, et al. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011-2012. http://www.cdc.gov/nchs/data/databriefs/db133.pdf. Published October 2013. Accessed December 23, 2015.
6. Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005;365:217-223.
7. Yoon SS, Ostchega Y, Louis T. Recent trends in the prevalence of high blood pressure and its treatment and control, 1999-2008. NCHS Data Brief 2010;48:1-8.
8. Ezzati M, Oza S, Danaei G, et al. Trends and cardiovascular mortality effects of state-level blood pressure and uncontrolled hypertension in the United States. Circulation 2008;117:905-914.
9. Borak J, Salipante-Zaidel C, Slade MD, et al. Mortality disparities in Appalachia: reassessment of major risk factors. J Occup Environ Med 2012;54:146-156.
10. Esch L, Hendryx M. Chronic cardiovascular disease mortality in mountaintop mining areas of central Appalachian states. J Rural Health 2011;27:350-357.
11. Hendryx M, Zullig KJ. Higher coronary heart disease and heart attack morbidity in Appalachian coal mining regions. Prev Med 2009;49:355-359.
12. Mamudu HM, Paul T, Veeranki SP, et al. Subclinical atherosclerosis and relationship with risk factors of coronary artery disease in a rural population. Am J Med Sci 2015;350:257-262.
13. Mamudu HM, Paul TK, Wang L, et al. The effects of multiple coronary artery disease risk factors on subclinical atherosclerosis in a rural population in the United States. Prev Med 2016;88:140-146.
14. Iqbal MT. An opportunistic pre-diabetes screening program offered with existing hypertension screening. J Prev Med Hyg 2013;54:14-16.
15. Michimi A, Ellis-Griffith G, Lartey G, et al. Variability between self-reported diabetes and measured glucose among health screening participants in South Central Kentucky. Prim Care Diabetes 2014;8:31-38.
16. Centers for Disease Control and Prevention. Estimated county-level prevalence of diabetes and obesity-United States, 2007. MMWR Morb Mortal Wkly Rep 2009;58:1259-1263.
17. DeVol R, Bedroussian A. An unhealthy America: the economic burden of chronic disease. Charting a new course to save lives and increase productivity and economic growth. http://assets1c.milkeninstitute.org/assets/Publication/ResearchReport/PDF/chronic_disease_report.pdf. Published October 2007. Accessed December 31, 2015.
18. Agatston AS, Janowitz WR, Hildner FJ, et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990;15:827-832.
19. National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-3421.
20. Halverson JA, Barnett E, Casper M. Geographic disparities in heart disease and stroke mortality among black and white populations in the Appalachian region. Ethn Dis 2002;12(S3):82-91.
21. Blumenthal SJ, Kagen J. The effects of socioeconomic status on health in rural and urban America. JAMA 2002;287:109.
22. Mensah GA, Mokdad AH, Ford ES, et al. State of disparities in cardiovascular health in the United States. Circulation 2005;111:1233-1241.
23. Melvin CL, Corbie-Smith G, Kumanyika SK, et al. Developing a research agenda for cardiovascular disease prevention in high-risk rural communities. Am J Public Health 2013;103:1011-1021.
24. Herath Bandara SJ, Brown C. An analysis of adult obesity and hypertension in Appalachia. Glob J Health Sci 2013;5:127-138.
25. Centers for Disease Control and Prevention. BRFSS prevalence and trend data. http://www.cdc.gov/brfss/brfssprevalence/index.html. Accessed February 15, 2016.
26. Centers for Disease Control and Prevention. Vital signs: prevalence, treatment, and control of hypertension-United States, 1999-2002 and 2005-2008. MMWR Morb Mortal Wkly Rep 2011;60:103-108.
27. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806-814.
28. Gillum RF, Sempos CT. Ethnic variation in validity of classification of overweight and obesity using self-reported weight and height in American women and men: the Third National Health and Nutrition Examination Survey. Nutr J 2005;4:27.
29. Merrill RM, Richardson JS. Validity of self-reported height, weight, and body mass index: findings from the National Health and Nutrition Examination Survey, 2001-2006. Prev Chronic Dis 2009;6:A121.
30. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obese in adults: the evidence report. http://www.nhlbi.nih.gov/files/docs/guidelines/obesity_guidelines_archive.pdf. Published September 1998. Accessed January 19, 2016.
31. Williams J, Wake M, Hesketh K, et al. Health-related quality of life of overweight and obese children. JAMA 2005;293:70-76.
32. Zeller MH, Roehrig HR, Modi AC, et al. Health-related quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics 2006;117:1155-1161.
33. Thorpe KE, Florence CS, Howard DH, et al. The impact of obesity on rising medical spending. Health Aff (Millwood) 2004;Suppl Web Exclusives: W4-480-6.
34. Wolf AM. What is the economic case for treating obesity? Obes Res 1998;6(Suppl 1):2S-7S.
35. Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood) 2009;28:w822-w831.
36. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-241.
37. Ogden CL, Flegal KM, Carroll MD, et al. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002;288:1728-1732.
38. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-1124.
39. Centers for Disease Control and Prevention. Diabetes report card 2014. http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf. Accessed January 20, 2016.
40. American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care 2008;31:596-615.
41. Barker LE, Kirtland KA, Gregg EW, et al. Geographic distribution of diagnosed diabetes in the U.S.: a diabetes belt. Am J Prev Med 2011;40: 434-439.
42. Centers for Disease Control and Prevention. National diabetes statistics report, 2014. https://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Published 2015. Accessed January 20, 2016.
43. Gu Q, Paulose-Ram R, Burt VL, et al. Prescription cholesterol-lowering medication use in adults aged 40 and over: United States, 2003-2012. NCHS Data Brief 2014;177:1-8.
44. Centers for Disease Control and Prevention. Physical activity and health: a report of the Surgeon General. http://www.cdc.gov/nccdphp/sgr/index.htm. Reviewed November 17, 1999. Accessed January 20, 2016.
45. US Department of Health and Human Services. The health consequences of smoking-50 years of progress: a report of the Surgeon General. https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. Accessed November 20, 2016.