Abstract
Background
The etiology of chronic venous disease in the lower limbs is unclear, and there are very limited data on potential risk factors from representative population studies.
Methods
Participants in the San Diego Population Study, a free-living adult population randomly selected from age, sex and ethnic strata, were systematically assessed for risk factors for venous disease. Categorization of normal, moderate disease and severe disease was determined hierarchically through clinical examination and ultrasound sonography by trained vascular technologists, who also performed anthropometric measures. An interviewer administered questionnaire and examination assessed potential risk factors for venous disease suggested by previous reports.
Results
In multivariable models, moderate venous disease was independently related to age, a family history of venous disease, previous hernia surgery, and normotension in both sexes. In men, current walking, the absence of cardiovascular disease, and not moving after sitting were also predictive, while in women, additional predictors were weight, number of births, oophorectomy, flat feet, and not sitting. For severe disease, age, family history of venous disease, waist circumference, and flat feet were predictive in both sexes. In men, occupation as a laborer, cigarette smoking, and normotension were also independently associated with severe venous disease, while in women additional significant and independent predictors were hours standing, history of leg injury, number of births, and cardiovascular disease, while African-American ethnicity was protective. Multiple other postulated risk factors for venous disease were not significant in multivariable analysis in this population.
Conclusions
Although some risk factors for venous disease such as age, family history of venous disease, and findings suggestive of ligamentous laxity (hernia surgery, flat feet) are immutable, others can be modified, such as weight, physical activity, and cigarette smoking. Overall, these data provide modest support for the potential of behavioral risk factor modification to prevent chronic venous disease.
Keywords: veins, peripheral vascular diseases, risk factors, epidemiology, varicose veins, venous insufficiency
Abnormalities of the veins in the lower limbs are responsible for significant and widespread morbidity. The prevalence of venous disease increases with age (1), and an aging world population is likely to result in an increase in venous disease. However, the etiology of chronic venous disease is poorly understood and only a limited number of potential risk factors have been explored, some with contradictory results. A recent review (1) showed that there are many hypotheses pertaining to the development of varicose veins, chronic venous insufficiency (CVI) and venous ulcers. The latter endpoint has been the most frequently explored in previous studies, but it is less common than other manifestations. In the San Diego Population Study (SDPS), we systematically examined the relationship of a wide variety of potential risk factors to both visible and functional venous disease. The risk factors considered included family history (2-9), connective tissue laxity (10-15), previous lower limb trauma (16, 17), cardiovascular disease (CVD) related factors (18, 19), positional factors (20-28), physical measures (29-36), smoking (6), constrictive clothing (37-41), a period of immobility (42), physical activity (6, 19), constipation (43-45), fiber intake (46, 47), and hormonal factors (48-51). This is a report of our findings.
MATERIALS AND METHODS
Population
The population for this study was randomly selected from current and retired employees of the University of California, San Diego (UCSD). Random selection was made within strata defined by age, sex, and ethnicity. The categories of 40-49 years, 50-59 years, 60-69 years and 70-79 years defined the age strata. Women were over-selected to allow additional power for certain female-specific hypotheses. Ethnic minorities—Hispanics, African-Americans, and Asians—were over-selected to allow statistical power for contrasts by ethnicity. The spouse or significant other of each randomly selected participant was also invited to participate in the study. Some volunteers (n=199) who had heard about the study and who asked to participate were enrolled. By selecting persons from all levels of education and occupation, and both working and retired, we were able to study a broad-based population sample.
For all study procedures, participants provided signed informed consent following a detailed introduction to the study. The study was approved by the Committee on Investigations Involving Human Subjects of UCSD and all participants provided voluntary informed consent.
Registered vascular technologists were trained and monitored for each component of the study visit. Particular attention was given to close adherence to the study protocol, which specifically defined the criteria for each of the venous conditions. Details of the protocol have been published (52).
Disease classification
In previous reports from the SDPS we separately characterized each leg of each participant by four categories of visible disease; normal, telangectasis or spider veins, varicose veins, or trophic changes, and by three categories based on duplex ultrasound evaluation; normal, superficial functional disease, or deep functional disease (52). Because of the large number of risk factors evaluated, for simplicity each leg for this report was classified in three overall, mutually exclusive, heirarchical categories, normal, moderate, or severe disease, as described below.
Normal
Persons without varicose veins, without trophic changes (lipodermatosclerosis, hyperpigmentation, healed ulcer or active ulcer upon visual inspection) and without insufficiency or obstruction of either the deep or superficial systems on inspection with Duplex ultrasound were classified as “normal”. This corresponds with C0 or C1 with Pn in the revised CEAP classification (53).
Moderate venous disease
Persons with varicose veins or reticular varices in the absence of trophic changes upon visual inspection, or with either insufficiency or obstruction of the superficial system or the perforating veins but not in the deep system by Duplex ultrasound were classified as having moderate disease. Limbs with a history of vein stripping in the absence of severe disease were classified as moderate. This corresponds with C2 or As or Ap in the revised CEAP classification (53).
Severe venous disease
Persons with trophic changes upon visual inspection or insufficiency or obstruction in the deep system by Duplex ultrasound were classified as having severe disease for this report. This corresponds with C4 or C5 or C6 or Ad in the revised CEAP classification (53).
Risk Factors
At the study visit trained interviewers followed a standardized protocol to obtain information on demographics, lifestyle, and past personal and family medical history. The vascular technologists assessed anthropometric measures.
Ethnicity and Occupation
Subjects self-defined their race/ethnicity as: “White, not Hispanic”, “Hispanic/Chicano”, “African American”, “Asian/Pacific Islander”, “Native American”, or “Other”. The subject’s current occupation (or last occupation if retired), was classified by the interviewer as “professional”, “technical/administrative/managerial”, “clerical/skilled”, “semi-skilled”, or “laborer”.
Personal Habits
Subjects estimated hours spent lying down, sitting, walking, and standing, currently and as adults. Subjects answered whether when sitting for long periods they regularly got up to move around currently and as adults. History of wearing constrictive clothing, including girdles, corsets, abdominal braces, and exercise attire was assessed. Subjects rated their level of physical activity relative to persons their own age. Subjects estimated how often they engaged in vigorous activity (with increased heart rate) for at least 20 minutes weekly. Smoking history, including current and average daily cigarette intake and years smoked was assessed. Standardized self-administered dietary assessment forms were analyzed by the Fred Hutchinson Cancer Research Center, Seattle WA (54).
Health History
Subjects’ cardiovascular health history, history of high blood pressure and diabetes were ascertained. Questions about immobility and bowel activity were asked. Side-specific determination was made of any serious lower limb injuries. Subjects’ history of hernia surgery, diverticulosis, diverticulitis, and non-lower limb vein abnormalities was assessed. Women were asked about their reproductive history. Subjects self-reported whether they had hypermobile joints and flat feet.
Family History
Family history (all first-degree relatives) of telangiectasis, varicose veins, blood clots in lower limb veins, phlebitis, venous ulcer, pulmonary embolism or other venous problems was assessed.
Anthropometrics
The subjects’ height, weight, heart rate, waist, and hip circumferences were measured. Blood pressures were measured in the right arm after the subject had been sitting quietly for five minutes. The standing foot-arch height was visually ranked as flat, small, or normal/high.
Quality Control
In a standardized fashion, interviewers were trained to administer the questionnaire protocol, and the vascular technologists were trained in the physical examination and duplex ultrasound protocol, with periodic assessment for quality control. The reliability data have been published (55). All numeric variables entered in the Microsoft Access database had range checks. A 2% random sample was further checked against the chart, and outliers for each individual variable were also systematically checked against the chart.
Statistical Analysis
All analyses were conducted using SAS 8.1 for Windows (56). Age-adjusted univariate analyses and all multivariable analyses used logistic regression. Multivariable analyses used entry criteria of p<0.3 and removal criteria of p>0.10 for forward step-wise logistic regression to develop the final models. Age and indicator variables for ethnicity were included in all models.
RESULTS
The study population consisted of 854 men and 1580 women with mean (standard deviation) ages of 60.1 (11.4) and 58.8 (11.4) respectively. The ethnic distribution was approximately 60 percent Non-Hispanic White (NHW), 15 percent Hispanic, 13 percent African-American, and 12 percent Asian. We have previously published the relationship of venous disease by sex, age and ethnicity in the study population (52). Table 1 shows the sex-specific percent distributions of moderate and severe disease in the SDPS by age and ethnicity. Both moderate and severe venous disease increased with age. Women had nearly twice the rate of moderate disease as men did, while men had higher rates of severe disease. The disease distribution was significantly different for men and women (chi-square p<0.0001). Hispanics had the highest rates of moderate and NHWs the highest rates of severe disease.
Table 1.
Demographic distribution of venous disease by age, sex, and ethnicity
MEN, % | WOMEN, % | |||||||
---|---|---|---|---|---|---|---|---|
AGE | N | NL | MOD | SEV | N | NL | MOD | SEV |
< 50 | 185 | 77.3 | 10.8 | 11.9 | 417 | 72.7 | 19.2 | 8.2 |
50-59 | 240 | 75.4 | 11.7 | 12.9 | 412 | 67.5 | 22.6 | 10.0 |
60-69 | 198 | 66.7 | 14.1 | 19.2 | 395 | 56.7 | 28.9 | 14.4 |
70+ | 201 | 59.2 | 15.4 | 25.4 | 356 | 52.3 | 30.6 | 17.1 |
ETHN | ||||||||
NHW | 560 | 67.3 | 14.1 | 18.6 | 876 | 60.4 | 25.7 | 13.9 |
Hisp. | 84 | 70.2 | 17.9 | 11.9 | 269 | 60.0 | 30.5 | 9.3 |
Af-Am. | 78 | 79.5 | 7.7 | 12.8 | 245 | 67.4 | 22.9 | 9.8 |
Asian | 102 | 77.5 | 6.9 | 17.7 | 190 | 71.1 | 17.4 | 11.6 |
* Some percentages do not total to 100 because of rounding.
Abbreviations: N=number, NL=normal, MOD=moderate, SEV=severe, ETHN=ethnicity, NHW=Non-Hispanic White, Hisp=Hispanic, Af-Am=African American
Table 2 shows the distribution of risk factors by venous disease category—Normal, Moderate, or Severe—and by sex. These variables were selected from a long list of potential risk factors because each showed univariate relationships with either moderate or severe venous disease. Thus they were included in the multivariable logistic regression models discussed below. Variables which showed no univariate associations included multiple dietary factors such as fiber intake, bowel habits and gastrointestinal problems, regular physical activity, and constrictive clothing.
Table 2.
Distribution of Risk Factors by Moderate and Severe Venous Disease
MEN, N=824 | WOMEN, N=1570 | |||||
---|---|---|---|---|---|---|
NL | MOD | SEV | NL | MOD | SEV | |
Weight, kg | 82.1 | 82.8 | 84.8 | 68.6 | 70.6 | 72.5 |
Waist, cm | 96.1 | 96.1 | 99.5 | 84.8 | 86.3 | 89.4 |
Current cigs/day | 0.7 | 0.9 | 1.5 | 0.6 | 0.4 | 0.6 |
Diastolic BP, mm/Hg | 79.0 | 77.7 | 76.2 | 75.9 | 76.5 | 75.3 |
Current walking, hrs | 4.6 | 5.4 | 4.9 | 4.9 | 5.4 | 5.0 |
Current standing, hrs | 3.4 | 3.1 | 3.2 | 3.3 | 3.5 | 3.7 |
Adult sitting, hrs | 7.6 | 7.1 | 7.3 | 7.4 | 6.6 | 6.7 |
History of CVD, % | 12.0 | 3.7 | 22.5 | 5.5 | 6.1 | 12.4 |
Hypertension, % | 36.4 | 28.0 | 42.3 | 32.5 | 30.9 | 44.0 |
Hernia Surgery, % | 15.7 | 29.9 | 21.8 | 3.2 | 7.3 | 6.7 |
Flat feet, % | 13.0 | 15.9 | 18.3 | 12.0 | 15.9 | 15.1 |
Flat arch, % | 10.2 | 9.5 | 12.7 | 5.6 | 7.0 | 12.7 |
Small arch, % | 27.9 | 26.7 | 30.6 | 23.0 | 24.4 | 29.1 |
Family hx ven. dis, % | 42.6 | 63.6 | 59.2 | 57.5 | 74.5 | 69.4 |
Leg injury, % | 26.3 | 28.0 | 28.9 | 19.9 | 20.7 | 28.0 |
Curr. move after sit , % | 96.0 | 92.5 | 95.8 | 96.0 | 96.7 | 97.4 |
Laborer, % | 2.3 | 2.8 | 5.6 | 1.3 | 1.5 | 1.6 |
Number of births | na | na | na | 2.0 | 2.6 | 2.5 |
Oophorectomy | na | na | na | 16.7 | 24.0 | 21.2 |
Abbreviations: N=number, NL=normal, MOD=moderate, SEV=severe, CVD=cardiovascular disease, BP=blood pressure, hx ven. dis=history of venous disease, Curr.=currently, na=not applicable
Multivariable models
Table 3. Moderate venous disease
Table 3.
Risk Factors for Moderate Venous Disease (vs. Normal) in Men and Women (multivariable entry into model 0.3, exit 0.1)
Men | Women | |||
---|---|---|---|---|
Variable | Point estimate | 95% CI* | Point estimate | 95% CI* |
Age (10 years) | 1.59 | 1.26, 2.00 | 1.43 | 1.25, 1.64 |
African-American | 0.64 | 0.25, 1.60 | 0.84 | 0.57, 1.24 |
Asian | 0.55 | 0.23, 1.29 | 0.90 | 0.57, 1.42 |
Hispanic | 1.48 | 0.74, 2.94 | 1.21 | 0.85, 1.70 |
Family Hx of Ven. Dis. | 2.87 | 1.81, 4.55 | 2.34 | 1.77, 3.10 |
Hernia Surgery | 1.85 | 1.09, 3.14 | 1.81 | 1.04, 1.34 |
Hypertension | 0.58 | 0.34, 0.98 | 0.64 | 0.47, 0.87 |
Current Walking (per hr) | 1.14 | 1.05, 1.24 | ---- | ---- |
CVD History | 0.22 | 0.08, 0.66 | ---- | ---- |
Curr. Move After Sitting | 0.31 | 0.13, 0.79 | ---- | ---- |
Adult Sitting (per hour) | ---- | ---- | 0.92 | 0.87, 0.96 |
Weight (10 kilograms) | ---- | ---- | 1.32 | 1.12, 1.56 |
Number of Births | na | na | 1.14 | 1.05, 1.23 |
Waist Circumf. (10 cm) | ---- | ---- | 0.83 | 0.69, 1.00 |
Oophorectomy | na | na | 1.37 | 1.00, 1.87 |
Flat Feet | ---- | ---- | 1.39 | 0.97, 2.00 |
CI = confidence interval
Abbreviations: Hx of Ven. Dis.=history of venous disease, CVD=cardiovascular disease, Curr=currently, Circumf.=circumference, na=not applicable
Four variables were highly significant for moderate disease in both men and women in multivariable analysis; age, family history of venous disease, previous hernia surgery, and hypertension. The odds ratios (OR) for age (per decade) were 1.59 in men and 1.43 in women; for family history, 2.87 and 2.34 respectively, and for hernia surgery 1.85 and 1.81 respectively. Hypertension showed an inverse relationship, with odds ratios of 0.58 and 0.64 respectively. All the confidence intervals for these associations excluded the null hypothesis. Although moderate disease, compared to NHW, was greater in Hispanics and less in African-Americans and Asians, none of these associations reached statistical significance.
Additional significant predictors in men, in order of statistical significance, were current walking (per hour), OR = 1.14; history of CVD, OR = 0.22; and a protective association for current moving around after sitting for long periods, OR = 0.31. In women, additional predictors in order of statistical significance were adult life sitting (per hour), OR = 0.92; weight (per 10 kilograms) OR = 1.32; number of births (per birth), OR = 1.14; waist circumference (per 10 cm), OR = 0.83; previous oophorectomy, OR = 1.37; and flat feet, OR = 1.39.
Table 4. Severe venous disease
Table 4.
Risk Factors for Severe Venous Disease (vs. Normal) in Men and Women (multivariable entry into model 0.3, exit 0.1)
Men | Women | |||
---|---|---|---|---|
Variable | Point estimate | 95% CI* | Point estimate | 95% CI* |
Age (10 years) | 1.41 | 1.17, 1.70 | 1.43 | 1.21, 1.68 |
African-American | 0.63 | 0.30, 1.35 | 0.44 | 0.26, 0.77 |
Asian | 1.50 | 0.81, 2.75 | 0.99 | 0.57, 1.74 |
Hispanic | 0.63 | 0.28, 1.39 | 0.71 | 0.42, 1.19 |
Family Hx of Ven. Dis. | 2.13 | 1.44, 3.16 | 1.92 | 1.33, 2.77 |
Waist Circumf.(10 cm) | 1.37 | 1.15, 1.63 | 1.24 | 1.11, 1.39 |
Laborer | 3.24 | 1.21, 8.67 | ---- | ---- |
Dias. BP (10 mm/Hg) | 0.80 | 0.67, 0.97 | ---- | ---- |
Current Cigs. (20/day) | 2.24 | 1.11, 4.54 | ---- | ---- |
Flat Feet | 1.63 | 0.97, 2.75 | ---- | ---- |
Flat Arch (vs. normal) | ---- | ---- | 3.28 | 1.83, 5.89 |
Current Stand. (per hr) | ---- | ---- | 1.14 | 1.05, 1.24 |
Small Arch (vs. normal) | ---- | ---- | 1.84 | 1.25, 2.71 |
Leg Injury | ---- | ---- | 1.67 | 1.14, 2.44 |
Number of Births | na | na | 1.14 | 1.03, 1.27 |
CVD History | ---- | ---- | 2.02 | 1.14, 3.56 |
CI = confidence interval
Abbreviations: Hx of Ven. Dis.=history of venous disease, Circumf.=circumference, Dias. BP=diastolic blood pressure, Cigs.=cigarettes, Stand.=standing, CVD=cardiovascular disease, na=not applicable
Three variables were highly significant for severe disease in both men and women in multivariable analysis; age, family history of venous disease, and waist circumference. The ORs in men and women respectively were 1.41 and 1.43 for age; 2.13 and 1.92 for family history, and 1.37 and 1.24 for waist circumference. The only significant association for ethnicity was a reduced odds of severe disease in African-American women, OR = 0.44. The data for men for African-American ethnicity were also suggestive (OR = 0.63), but the confidence interval included one.
Additional significant predictors in men, in order of statistical significance, were occupation as a laborer, OR = 3.24; diastolic blood pressure (per 10 mm/Hg), OR 0.80; current cigarettes per day (per 20 cigarettes), OR = 2.24; and flat feet, OR = 1.63. In women, additional predictors in order of statistical significance were flat (OR = 3.28) or small (OR = 1.84) foot arch; current standing (per hour), OR = 1.14; previous leg injury, OR = 1.67; number of births (per birth), OR = 1.14 and history of CVD, OR = 2.02.
DISCUSSION
Age, sex, and ethnicity were important risk factors for venous disease, as in most previous studies (1, 52). Our results confirm that older age is a risk factor for venous disease. They also showed no significant ethnic differences for moderate disease, but significantly less severe disease may be more common in African-American women.
Family history was a risk factor for both moderate and severe disease. Many studies have found an association with family history and venous disease (2-7), although not all (8, 9). As other researchers have pointed out, biased recall could have influenced this finding (9, 57). Nevertheless, in our study family history based on subject recall was a very strong risk factor for venous disease. In addition, Table 2 shows subjects without venous disease reported high rates of a family history of venous disease.
Connective tissue laxity, as manifested by previous hernia surgery or findings of flat feet, was a consistent risk factor for both moderate and severe disease. The association of increasing laxity in connective tissue with venous disease corroborated previous research (10-13). It is possible that previous hernia surgery may have been a marker for previous hospitalization and immobility. However, the latter variable was not significantly associated with venous disease in our data.
Lower limb injury was a risk factor in women for severe disease. This finding corresponds with the results of Bermudez et al. who noted that insufficiency in the deep veins was increased in limbs that had experienced trauma in comparison with limbs that had not (16). Similarly, a case-control study found serious lower limb trauma to be a risk factor for CVI (8). However, an earlier study found no difference in CVI for injured versus uninjured limbs (17).
CVD-related factors, specifically hypertension, previous CVD, and higher diastolic blood pressure were associated with less moderate disease for both men and women and less severe disease for men. Conversely, a history of CVD was strongly associated with severe disease in women. Although some studies have found a relationship between atherosclerosis and venous disease (18, 19), others have not (3). The reason for any protective effect of atherosclerosis on moderate or severe venous disease is not readily apparent, although relative arterial insufficiency, venous vasoconstriction and microthrombosis could conceivably be involved.
Positional factors such as walking, standing, and sitting showed variable associations with venous disease. In women, increased time standing was positively associated with more severe disease, and increased sitting time inversely associated with moderate disease. For men, increased daily walking was associated with moderate disease, and men who worked as laborers were more likely to have severe disease than those in positions which typically require more desk time. Regular movement when sitting for long periods was related to lower rates of moderate disease in men. Fowkes et al. similarly found that sitting was associated with lower rates of venous insufficiency for women and not for men (20). Fowkes et al. also found that walking was a risk factor for women with venous insufficiency when age-adjusted, but less so when multiply adjusted. They found walking to be related to lessened risk of venous insufficiency in men (20). Our data indicate that standing was a strong risk factor for severe venous disease in women. This is concordant with a number of studies (3, 4, 6, 7, 21-26), and contrasts with some other studies (9, 20, 27, 28). Our finding that moving about if sitting for long periods of time was related to lower rates of moderate disease for men concurs with the hydrostatic model of venous disease. That is, while sitting and lying are generally more protective than walking or standing, there is still the possibility for some pooling of blood during the former activities. Moving about could activate the venous pump and prevent such pooling.
Physical measures were risk factors for women with both severe and moderate disease, and men with severe disease. Weight and waist circumference are both measures of adiposity. A number of studies have found an association of obesity with venous disease. Both Sisto et al. (29) and Gourgou et al. (6) found a relationship in both men and women with varicose veins; and Widmer and Abramson et al. both found an association for women (21, 30), and Beaglehole found an association for men (36). Our finding of increased waist circumference in both sexes with severe disease was consistent with Scott’s findings that obesity was associated with CVI and with Mota-Capitao et al.’s finding that weight was an independent risk factor for CVI in multivariable analysis (5, 31). In contrast, Coughlin et al. and Fowkes et al. both found that obesity was not a factor in venous insufficiency among women (8, 20). Fowkes et al. extended this finding to men as well (20). Other studies have also found no association between obesity and venous disease (3, 28, 32-34). However, the Edinburgh group also found that for men and women combined, persons with more segments with reflux had higher body mass indices than those with fewer or no segments involved (20).
Hormonal factors in women, number of births and oophorectomy, were related to moderate and/or severe venous disease. Gourgou et al. and Laurikka et al. found increasing varicose vein prevalence with increasing numbers of births (6, 7). Coughlin et al. found that multiparity was associated with varicose veins in pregnant women (8), as did Sisto et al., Maffei et al. and Sohn et al. (28, 29, 48). Some studies have found that the changes occur with only one pregnancy (3, 4, 21, 30). In Guberan et al. and Lee et al., pregnancy was no longer a risk factor once the data had been age-adjusted (22, 49). In two studies, Sparey et al. evaluated women with and without varicose veins at the beginning of pregnancy (50, 51). While neither group developed new varicose veins during pregnancy, both had dilation of veins during pregnancy and, in women without varicose veins, the diameter had not returned to baseline size by 6 weeks postpartum.
Smoking was associated with increased rates of severe disease for men. One study has shown that VV was associated with higher numbers of cigarettes smoked per day (6), but this is the first report of a sex-specific association limited to severe venous disease.
Constrictive clothing, Immobility, Exercise, Constipation, and Dietary Fiber were not risk factors for either moderate or severe disease in multivariable models. Multiple questions addressed each of these five categories of potential risk factors, but none were statistically significant in multivariable analysis. Thus, despite biologic plausibility for such factors and some earlier reports, in this large population-based study we were unable to confirm the importance of such factors in peripheral chronic venous disease.
Limitations of these results include the cross-sectional study design, where correlations do not necessarily imply causation. Additionally, some of the risk factors reviewed were self-reported and there was no formal validation of the subjects’ responses. A specific concern in this area was the strong and independent association of a family history of venous disease for both men and women and for both moderate and severe disease, which could to some extent reflect recall bias. However, roughly half the participants with normal veins reported a family history of venous disease, so such reporting was common in those with and without venous disease.
CONCLUSION
This comprehensive cross-sectional study of venous disease helps to clarify the contributions of a variety of risk factors to moderate and severe venous disease. Our data indicate that age, family history, and ligamentous laxity were the strongest and most consistent risk factors for venous disease. None of these conditions is amenable to intervention, and thus these findings have little implication for disease prevention. CVD-related factors were generally associated with lower rates of venous disease.
However, a number of behavioral and environmental factors did show significant relationships. Among volitional factors important findings were: central adiposity, positional factors such as hours spent standing or sitting, cigarette smoking, and parity in women, and all but the latter variable are reasonably subject to intervention. In addition, prevention of or intervention on obesity and cigarette smoking would have also show benefit for conditions such as CVD and cancer. In women (but not men) we confirmed the importance of a previous lower limb injury for severe disease. These data provide modest support for the potential of behavioral risk factor modification to prevent chronic venous disease.
Incidence studies would provide greater understanding of the role of risk factors in the development and progression of moderate and severe venous disease.
Acknowledgments
This research was supported by National Institutes of Health–National Heart, Lung, and Blood Institute grant 53487 and National Institutes of Health General Clinical Research Center Program grant MO1 RR0827.
Abbreviations
- CVI
Chronic Venous Insufficiency
- CVD
Cardiovascular Disease
- UCSD
University of California, San Diego
- CEAP
Clinical, Etiological, Anatomic and Pathophysiological
- NHW
Non-Hispanic White
Footnotes
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