Are Health Behaviors and Risk Factors for Altherosclerotic Cardiovascular Disease Interrelated Among Older Filipinos in Underserved Communities?

Abstract

Introduction:

Moving individuals toward ideal cardiovascular health through adoption of healthy lifestyle behaviors is critically important for prevention of atherosclerotic cardiovascular disease (ASCVD) and other important health conditions. However, associations between health behaviors and risks for ASCVD is poorly understood among older adults (≥ 60 years) living in rural areas in the Philippines. Likewise, their access to healthcare and health-seeking practices are unknown.

Purpose:

To 1) compare risk profiles of Filipinos at low- vs. moderate to high-risk for ASCVD; and 2)examine the relationships befiveen demographic variables, risk profiles, and health behaviors.

Methods:

A convenient sample of 427 Filipinos (≥ 60 years old) were recruited to participate in this comparative, cross-sectional study. Data on sociodemographic characteristics, risk profiles, and health behaviors (e.g., dietary patterns, physical activity, smoking status,and alcohol use)were collected.

Results:

Of the 427 participants (mean age was 69.2± 6.7 years, primarily women [65%], married [52.8%]), 319 (75%) were at low-risk and 108 (25%) were at moderate to high-risk for ASCVD. Those at moderate to high-risk were more likely to have cardiometabolic diseases(e.g., hypertension, hyperlipidemia, diabetes, and obesity, all p’s < .001).Health behaviors did not differ between the two groups except for consumption of≥ 5 servings of fruit which was higher in the low-risk group.

Conclusion:

Findings showed that there is highly consistent and convergent evidence that older Filipinos living in rural areas are at high risk for ASCVD and other health conditions. Much of this is attributable to the suboptimal implementation of prevention strategies, uncontrolled ASCVD risk factors, and poor access to effective and equitable healthcare services commonly observed in low-income countries. Clinicians, researchers, policy makers, and other stakeholders need to address these issues to improve primary and secondary prevention and disease management in this population.

Graphical Abstract

Introduction

Atherosclerotic cardiovascular disease (ASCVD) is a global epidemic that affects morbidity and quality of life of all racial and ethnic populations.¹ It is the leading cause of death worldwide; predictions show that by 2025, 80–90% of all deaths in the world will occur in low- and middle-income countries.² The estimated cost of healthcare services, medications, and lost productivity associated with ASCVD in the U.S. alone is estimated at more than 200 billion annually.³

Although the U.S. has made major strides in attaining the WHO’s impact goal of improving cardiovascular health and reducing the rates of premature deaths associated with ASCVD by one-third through prevention and treatment,⁴ these efforts are abysmal in low- and middle-income countries.^2,4,5 Much of this is attributable to the suboptimal implementation of prevention strategies, uncontrolled ASCVD risk factors -- hypertension, diabetes, elevated cholesterol, tobacco use, overweight/obesity -- also referred to as cardiometabolic diseases (CMD),⁶ and poor access to effective and equitable healthcare services (including early detection services) in individuals from these countries.^2,7 Older adults are at greater risk for both ASCVD and CNID.³ Given the high prevalence of ASCVD among older adults in low-and middle-income countries like the Philippines, the projected increase in this population will be a major challenge for the country’s health care system.⁸

Research also suggests that ASCVD is interrelated with health behaviors (e.g., poor eating habits, high sedentary behaviors, smoking and alcohol use, and overweight and obesity.⁸ While eating healthier, increasing physical activity levels, avoidance of alcohol use and/or smoking or its cessation, and weight maintenance are recommended for prevention of ASCVD,² millions of older adults worldwide do not receive key evidence-based preventive services.⁵ Rural populations are especially disadvantaged with multiple health care disparities, resulting in lower rates of primary and secondary risk prevention measures.⁸ This is especially true in Filipinos in the U.S. who are at higher risk for both ASCVD and CBD. In a study conducted among older Asian Americans in California, Filipinos along with their Vietnamese counterparts tended to have poorer physical health and reported the greatest number of chronic diseases including asthma, high blood pressure, and heart disease and the highest level of disability.⁹ Another study found older Filipinos in the U.S. to be at high risk of hypertension, coronary heart disease, diabetes mellitus at midlife and old age, and other metabolic problems.¹⁰ While there have been many studies exploring health characteristics of Filipino Americans compared across different subcategories of Asian Americans in the U.S., ⁹ there is a paucity of research examining health behaviors among Filipinos in their native country. Likewise, there is little data on the number of Filipinos in the Philippines who have access to evidence-based preventive services to support healthy lifestyle behaviors.

Moving individuals toward ideal cardiovascular health are critically important for the prevention of many important health conditions.¹¹ The most important way to prevent ASCVD is to promote a healthy lifestyle throughout life.^5,6 Observational data indicate that adhering to a healthier lifestyle was associated with lower risk for ASCVD ¹² whereas a high-quality diet, regular exercise, and smoking cessation lowered morbidity and mortality.¹³ While the literature is replete with studies examining prevention strategies focused on improving diet, physical activity, and avoidance of alcohol and tobacco use, and weight management,^3,11 there is a dearth of studies examining these health behaviors and their association with risks for ASCVD in low-income countries like the Philippines. This study was conducted to overcome the current gaps in research as clearly depicted in the foregoing sections. The specific aims of this comparative, correlational study are to l) compare health behaviors of older Filipinos at low- vs. high-risk for ASCVD; and 2) examine the relationships between sociodemographic characteristics, risk profiles, and health behaviors.

Methods

A comparative, cross-sectional design was used to conduct a secondary analysis of data from a nationally representative cohort of Filipinos living in underserved communities in the Philippines who participated in extensive interviews conducted by trained bilingual (English and Tagalog) community workers. The methodological approach, including the interview and survey guides developed by the U.S. Department of Health and Human Services describing efforts to build partnerships within Filipino communities in the U.S. and focus local community action on creating heart disease prevention activities,¹ were replicated for this study. The overall goal of the parent study was to examine perceptions and knowledge of heart disease and motivation to making lifestyle changes in underserved communities in the Philippines.

For the study, 1203 participants, age between 18 and 83 years were recruited from the National Capital Region, Cordillera Administrative Region, Ilocos Region, Central Luzon, and Western and Central Visayas. For the current study, only data from 427 older participants (≥ 60 years old) were included. The study received Institutional Review Board approval from both universities involved. Written informed consent was waived given the low risk nature of the study. Data used for this secondary analysis were de-identified.

Sociodemographic variables and cardiometabolic risk factors

Sociodemographic characteristics including age, gender, marital status, education, and income were collected using a standardized form created for this study. The community workers who conducted the interviews helped assess each participants’ risk for ASCVD using the non-lab Framingham algorithm, which substituted body mass index (BMI) for lipids in the laboratory based Framingham algorithm. The non-lab algorithm was previously tested in a cohort of African Americans and shown to have higher sensitivity that led to better detection of at-risk cases and higher specificity that led to fewer false positive case.14 For the current study, participants at low-risk (n = 3 19) were compared to participants considered at moderate and high risk (n = 108), defined as a ≥ 10% chance of developing ASCVD. ¹⁵

Data on presence or absence (i.e. yes/no) of cardiometabolic risk factors were obtained using self-report and included 1) hypertension, defined as systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg and/or self-reported treatment with antihypertensive medication(s) during the two weeks before the interview; 2) type 2 diabetes, defined as previous diagnosis based on a fasting plasma glucose level of ≥ 126 mg/dL, a random plasma glucose, or 2-hour plasma glucose level of ≥ 200 mg/dL during a 75-g oral glucose tolerance test, or a glycosylated hemoglobin (AIC) ≥ 6.5%; 3) hyperlipidemia, based on lipid profile lab values - total cholesterol ≥ 200, low density lipoprotein ≥ 100 mg/dL, high density lipoprotein < 40 for men or < 50 for women, and triglycerides ≥ 140 mg/dL; and 4) overweight and obesity, defined as ≥ 23 kg/m2based on standards for Asian populations.¹⁶

Health Behaviors

Health behaviors were collected using a general health survey. To simplify choices for participants, we used binary variables similar to the collection of data for cardiometabolic risk factors. For example, physical activity was defined as engaging in ≥ 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity, based on American Heart Association Guidelines.³ Healthy dietary patterns were defined as consuming five or more servings of fruits and vegetables (at least 400 grams per day); fewerthan five servings were categorized as insuffcient. ¹⁷ Tobacco use was classified as never, previous smoker or current smoker, while alcohol consumption was based on presence or absence of moderate drinking defined as of up to one drink per day for women and up to two drinks per day for men. ¹⁷

Results

Of the 427 participants (mean age was 69.2± 6.7 years, primarily women [65%], married [52.8%]), 319 (75%) were low-risk and 108 (25%) were moderate to high-risk for ASCVD. Demographic characteristics were comparable between the two groups (Table 1). Differences in risk profiles between those at low- and moderate to high-risk are also illustrated in Table 1. Those at moderate to high-risk were more likely to have cardiometabolic diseases (e.g., hypertension, hyperlipidemia, diabetes, and obesity [i.e. measured by BMI and waist circumference])(all p’s < .001). Health behaviors did not differ between the two groups except for consumption of ≥ 5 servings of fruit which was higher in the low-risk group (Table 2).

Table 1.

Demographic and Risk profiles of Low- vs. Moderate to Higt-Risk Older Adults

	All Participants (N = 427)	Low-Risk Group (n = 319)	High-Risk Group (n= 108)	P value
Age, years (Mean±SD)	69.2± 6.7	69.1± 7.0	69.5± 6.4	.588
Female, N (%)	277 (64.9)	201(63.0)	76 (70.4)	.166
Married, N (%)	230 (52.8)	176 (55.2)	54 (50.0)	.278
≤ High schooleducation, N (%)	324 (75.9)	243 (76.2)	81 (75.0)	.919
Waist Circumference, inches (Mean ± SD)	34.2± 3.7	33.2± 3.5	35.2± 4.0	<.001
Body Mass Index (Mean ± SD)	24.5± 4.9	22.3± 4.5	26.8± 5.3	<.001
Body Mass Index Categories, N (%)				<.001
Underweight	45 (11.0)	44(13.2)	1 (0.9)
Normal weight	258 (60.4)	220 (69.0)	38 (35.2)
Overweight or Obese	124 (29.0)	55 (17.2)	69 (63.9)
Systolic Blood Pressure (Mean ± SD)	131.2± 15.3	127.6± 15.2	134.8± 15.4	<.001
Diastolic Blood Pressure (Mean ± SD)	84.5± 12.8	84.6± 15.7	84.4± 10.0	.958
Hypertension, N (%)	313 (73.3)	207 (64.9)	106 (98.1)	<.001
Hyperlipidemia, N (%)	145 (33.9)	66 (20.7)	79 (73.1)	<.001
Diabetes mellitus, Type 2 N (%)	130(30.4)	52(16.3)	78 (72.2)	<.001
Depression, N (%)	91 (23.1)	65 (21.4)	26 (24.1)	.567

Table 2.

Health Behaviors of Low- vs. Moderate to High-Risk Older Adults

Affirmative response to the following (yes)	All Participants (N = 427)	Low-Risk Group (n = 319)	High-Risk Group (n= 108)	P value
≥ 150 minutes physical activity/week, N (%)	280 (65.6)	214(67.1)	66 (61.1)	.259
< 4 hours of sedentary activity/day, N (%)	74 (37.5)	51(16.0)	23 (21.5)	.110
≥ 5 servings of vegetables/day, N (%)	48 (22.7)	34(10.7)	14(12.0)	.431
≥ 5 servings of fruits/day, N (%)	39(17.3)	31 (9.8)	8 (7.5)	.001
1 drink/day - women/2 drinks/day - men, N (%)	34.2± 3.7	73 (23.0)	20(18.5)	.812
Current smoker, N (%)	100 (23.4)	77 (24.1)	23 (21.1)	.240

Moderate to high-risk status was associated with adiposity (e.g., BMI, waist circumference), elevated systolic blood pressure, and a history of hypertension, hyperlipidemia, and diabetes (Table 3). Female gender was associated with higher waist circumference and Blvfl but lower systolic blood pressure; being female was also associated with having a higher risk for diabetes. Low fruit consumption, below the recommended intake of ≥ 5 servings per day was associated with female gender, higher BYII, and lower likelihood of having a history of hypertension.

Table 3.

Correlation Matrix for Key Variables (N = 427)

Variables	1	2	3	4	5	6	7	8	9
1 Risk status (↑ risk)	1.000
2 Gender	.067	1.000
3 Waist Circ.	.231**	..096*	1.000
4 Body mass index	.387**	129**	.383**	1.000
5 Systolic BP	.201**	−.095*	.262**	.160**	1.000
6 Hx., hypertension	.321**	.044	144**	.107*	.290**	1.000
7 Hx., hyperlipidemia	.482**	−.032	.166**	170**	.200**	.232**	1.000
8 Hx., diabetes	.528**	103*	.094	.093	−.012	.250**	.095*	1.000
9 ≤ 5 servings of fruit	.019	.098*	.031	.181**	−.003	−.127**	.044	−.038	1.000

^**Correlation is significant at the 0.01 level (2-tailed);

^*correlation is significant at the 0.05 level (2-tailed); Circ., circumference, Hx. History

Discussion

In 2010, the World Health organization (WHO) reported that older people, ≥ 60 years old comprise 13% of the population in the Western Pacific Region with 78% living in low- and middle-income countries.²⁰ The Philippines, belonging to this region, was reported to have 5.7% older persons in its general population in the same year. The WHO further notes that non-communicable diseases comprise 90% of the total disease burden of men and women ≥ 70 years old in the WPR in 2012. Of the non-communicable diseases, ASCVD was the leading cause of morbidity both in the Philippines and WPR, with more men inflicted by this condition than women.²⁰,²¹ Globally, 17.9 million people succumb to ASCVD, accounting for 31% of deaths worldwide. More than 75% of these deaths occur in low-and middle-income countries.²¹ According to the Department of Health in the Philippines ASCVD is among the top 4 leading causes of death in the country. ¹⁸ As the number of older adults worldwide is projected to increase by approximately 4% in 2030,²¹ strategies are needed to prepare for the challenges confronting an aging population and their increased risk for ASCVD and its complications. ²⁰ The WHO’s recommendations for improving cardiovascular health and reducing the rates of premature deaths associated with ASCVD is through prevention, early recognition, and treatment of CMD.⁴

In 2013, the prevalence rates of the major CMD risk factors among adults ≥ 20 years old in the Philippines included: diabetes (5.4%), hypertension (22.3%), dyslipidemia, low high density lipoprotein (71.3%), obesity, BMI kg/m2 (31.1%), and smoking (25.4%).26An unpublished report in 2016 revealed a 27% prevalence of metabolic syndrome.²⁸ In 2008, Sy and colleagues conducted the National Nutrition and Health Survey II (NNHeS II),a survey assessing the prevalence of non-communicable or lifestyle-related conditions and corresponding risk factors among Filipino adults ≥ 20 years old.²² This succeeds 2 other national surveys done in 1998 and 2003. The 2008 survey showed an increase in the prevalence of hypertension in the general adult population by 4.2% from that of 2003 (16.4%); older adults (≥ 65 years) were three times more likely to be diagnosed with hypertension,²² which is consistent with studies conducted in the U.S.²⁴

As with hypertension, type 2 diabetes places a person at higher risk for ASCVD.²³ The prevalence of type 2 diabetes is associated with increased morbidity and mortality, increased risk for ASCVD and other complications, increased risk of hospitalization or institutionalization, decreased functional status, and increased economic losses.²⁵ Globally, the incidence of diabetes increased four-fold from 108 million in 1980 to 422 million in 2014.26 More than 25% of adults, ≥ 65 years old in the U.S. suffer from type 2 diabetes.²⁷ Surprisingly, the rates of type 2 diabetes among older Filipinos in this study was 5% higher than older adults in the U.S. and almost six-fold higher than the latest 2013 Philippine NNHeS of the general adult population. This poses a major problem on our already limited resources as a recent study in Manila showed that adults diagnosed with type 2 diabetes also had greater diabetic complications and CIVD risk factors.²⁹

Unlike studies with Caucasian cohorts where obesity is highly associated with type 2 diabetes, type 2 diabetes among Filipinos is not commonly associated with obesity. The prevalence of obesity in the Philippine NNHeS of 2008 was less than but visceral adiposity was observed in 65.5% of women which suggest that visceral adiposity and not obesity per se was a more influential risk factor for type 2 diabetes.²⁵ In this study, diabetes was associated with hypertension, gender, and dyslipidemia. However, there was no significant association between diabetes, BN’II, and waist circumference. This may be attributed to the varied topogaphy and cultural milieu of the different regions in the Philippines that shape the heterogeneous lifestyle, activity, and food preferences of Filipinos. This has to be considered in developing strategies for preventing disease.²⁵

The WHO has the following estimates in 2016: 1) there are 1.9 billion adults, >18 years old, who are overweight, 650 million of which are obese; 2) the adult prevalence of obesity is 13%, with the women having a 4% higher prevalence than men; and, 3) the prevalence of obesity has increased by almost three-fold from 1975 to 2016.³¹

The prevalence of obesity in this study is five-fold more than the general adult population. Our findings are consistent with the increasing prevalence of obesity worldwide, as uncovered by numerous studies.³⁰ Likewise, the Philippines NNHeS data showed an upward trend in overweight and obesity from their surveys in 1987 through 2008. The general Filipino adult prevalence of overweight almost doubled from 11.8% in 1987 to 21.4% in 2008 while the obesity prevalence tripled from 1.7% in 1987 to 5.2% in 2008.³³ The Economist Intelligence Unit (2017), in a report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition (ARoFIIN), stated that the steadily increasing prevalence of obesity and overweight in the ASEAN region can be attributed to greater incomes, urbanization, changing health behaviors, and globalization.³² ARoFIIN notes that although the prevalence of obesity in the Philippines is still low, healthcare costs for obesity and obesity-related problems were between 4.11% to 7.87% of the national healthcare spending. ARoFIIN further reports that among the six sample countries in the ASEAN, the most significant reductions in productive years due to obesity were found in the Philippines (8 to 12 years). We speculate that these findings are related to the decreased functional capacity and poorer quality of life reported by individuals suffering with overweight and/or obesity.^”30

Hyperlipidemia was reported in approximately a third of the sample for the current study and is consistent with global prevalence of hyperlipidemia of 39% as reported by the WHO.³⁴ However, data from the NNHeS from 2008 showed that 72% of the sample had hyperlipidemia.²² This inconsistency maybe related to the age, where younger adults may have had higher levels of hyperlipidemia which increased the overall prevalence. Our findings corroborates established facts that hyperlipidemia is associated with higher risks for ASCVD, overweight or obesity and hypertension.

Lifestyle changes such as a healthy diet, physical activity or exercise, and smoking cessation are necessary to reduce CNID risk factors. Smoking prevalence among older adults in this study was lower (7.6%) compared to the NNHeS study of the general adult population in the Philippines (31%) ²² The WHO reports a declining trend in smoking rates worldwide except for data from the Eastern Mediterranean and African regions. ³⁵ The prevalence of smoking in Filipino adults by also decreased by 4.9% in 2008 compared to the 2003 NNHeS.²²

The prevalence of CNID risk factors increases with age and can partially explain the high prevalence rates in this study. National and global trends, likewise, show increase in prevalence in the general adult population. These CMD risk factors, either on its own or in conjunction with the others, all have significant physical, psychological, social, and economic implications to individuals, families, society, and the globe. Clearly, additional strategies are needed that target unhealthy lifestyle behaviors (e.g., poor eating habits, high sedentary behaviors, smoking and alcohol use, and overweight and obesity) of older Filipinos living in underserved areas in the Philippines.⁸ Programs that support primary and secondary risk prevention measures for ASCVD (e.g., eating healthier, increasing physical activity levels, avoidance of alcohol use and/or smoking or its cessation, and weight maintenance)⁵ should be recognized as a health care priority in the Philippines, especially in older adults living in rural areas where health care access is also a problem.⁸

It is important recognize that although we had a fairly large sample, we were limited in terms of the geographic areas where participants were recruited. We were unable to recruit from any of the regions in Mindanao because of the current political-social disarray on the island. Thus, results should not be generalized to the larger Filipino community in the Philippines. Epidemiological studies and qualitative research to further assess ASCVD risks are warranted. Mixed-methods research, especially studies conducted in partnership with health care clinics and the Department of Health would enhance the capacity to develop more informed and effective prevention programs for ASCVD.

Conclusion

Our findings confirm reports from the Department of Health that risks for ASCVD is highly prevalent in older Filipinos living in rural areas. Atherosclerotic cardiovascular disease is the leading cause of death for Filipinos, representing about 32% of all Filipino deaths.¹⁸ One of the major risk factors that is quite prevalent among Filipinos both in the U.S. and in the Philippines, and increases their risk of ASCVD, is hypertension.⁹ Seventy-three percent of older Filipinos who participated in the current study suffer from hypertension and approximately one-third suffer from hyperlipidemia and diabetes. In addition, one-fourth of the sample were current or previous smokers. Thus, community-based programs to promote healthy eating patterns and improve screening, referral, and follow-up for hypertension as well as programs to support smoking cessation may help reverse the increasing prevalence of ASCVD in this population. By conducting studies of risks behaviors among a subgroup of older Filipinos living in low-income communities in the Philippines, we were able to gain a greater understanding of the heart health problems that plague this population, and how to prevent them to help enhance the overall wellbeing of older Filipinos nationwide.