The majority of risk factors for cardiovascular diseases [CVDs] are modifiable. Continuous monitoring and control of these factors could significantly reduce the risk of CVDs-related morbidity and mortality. This study estimated the prevalence of modifiable risk factors in Indonesia and its co-occurence of multiple risk factors stratified by prior CVDs diagnosis status and sex.
Methods
Adult participants [> 15 years, N = 36,329, 57% women] with median age of 40 years were selected from a nationwide Indonesian cross-sectional study called Basic Health Research or Riset Kesehatan Dasar [Riskesdas] conducted in 2018. Thirteen risk factors were identified from the study, including smoking, a high-risk diet, inadequate fruit and vegetable consumption, a low physical activity level, the presence of mental-emotional disorders, obesity, a high waist circumference [WC], a high waist-to-height ratio [WtHR], hypertension, diabetes, a high total cholesterol level, a high low-density lipoprotein [LDL] cholesterol level, and a low high-density lipoprotein [HDL] cholesterol level. Age-adjusted prevalence ratios stratified by CVDs status and sex were calculated using Poisson regression with the robust covariance estimator.
Results
CVDs were found in 3% of the study population. Risk factor prevalence in the overall population ranged from 5.7 to 96.5% for diabetes and inadequate fruit and vegetable consumption respectively. Smoking, a high-risk food diet, and a low HDL cholesterol level were more prevalent in men, whereas a low physical activity level, the presence of mental-emotional disorders, obesity, a high WC, a high WtHR, hypertension, diabetes, a high total cholesterol level, and a high LDL cholesterol level were more prevalent in women. Approximately 22% of men and 18% of women had at least 4 risk factors, and these proportions were higher in participants with prior CVDs diagnosis.
Conclusions
There is a high prevalence of modifiable risk factors in the Indonesian adult population. Sex, age, and the presence of CVD are major determinants of the variations in risk factors. The presence of multiple risk factors, which are often inter-related, requires a comprehensive approach through health promotion, lifestyle modification and patient education.
Peer Review reports
Background
Cardiovascular diseases [CVDs] is a major cause of morbidity and mortality worldwide [1]. Although the risk factors underlying CVDs are well known and, for the most part, preventable, the prevalence is still increasing [2]. Prevention guidelines recommend lowering the risk by influencing modifiable risk factors to reduce morbidity and mortality [3, 4]. The prevalence of CVDs is also increasing in Southeast Asia, including Indonesia, increasing from 4.8 to 5.3% between 2014 and 2019 [5]. In Indonesia, the prevalence of CVDs varies according to geographic and demographic characteristics, including between men and women, presumably due to differences in exposure to risk factors [6]. Furthermore, there are significant gender differences in the presence risk factors and the occurrence of CVDs. Although men have a higher risk of coronary heart disease [CHD], women have an equal or even higher risk for stroke [7, 8].
Considerable evidence has shown that many cardiovascular risk factors are inter-correlated, and exposure to multiple factors significantly increases the risk of CVDs incidence [9]. For example, hypertension, type 2 diabetes, hyperlipidemia, and obesity are closely related to unhealthy behavior and lifestyle such as smoking, high risk food diet, low physical activity,and stress [10].
Limited information is available regarding the variation, burden, and co-occurrence of cardiovascular risk factors in the Indonesian population. Reliable epidemiological data of modifiable risk factors prevalence and variation among the Indonesian population are fundamental in shaping the strategic approach to decreasing the risk of CVDs. Therefore, the aims of this study are [1] to provide up-to-date prevalence of modifiable risk factors, [2] to describe the variations in risk factor distribution in the populations with a prior CVDs diagnosis [secondary prevention population] and without a CVDs diagnosis [primary prevention population], and sex. In addition, [3] to describe the extent of co-occurrence of multiple risk factors in the Indonesian adult population.
Methods
Study design and data source
The current study is based on the National Basic Health survey, or Riset Kesehatan Dasar [Riskesdas]. This five-year cross-sectional study began in 2007 and was conducted throughout the country by the Ministry of Health, the Republic of Indonesia. The principal aim of the Riskesdas was to provide information to the Indonesian government concerning population health status and associated risk factors [6]. Detailed information about the study design, data management, and methods of the Riskesdas has been described previously [11]. In brief, the target sample was 300.000 households from 30.000 pre-listed census blocks [CBs] provided by the Indonesian Central Bureau of Statistics. These CBs are distributed among 34 provinces in 514 districts/cities throughout Indonesia. Recruited and well-trained enumerators visited every randomly selected household and invited all its members to participate in a questionnaire-based interview. Furthermore, height, weight, waist circumference [WC], and blood pressure measurements were obtained.
Adult household members [15 years and older] from 2500 CBs in 26 provinces were sub-sampled to represent national-level prevalence estimates for blood examinations [fasting [FBG] or random blood glucose [RBG] and cholesterol profiles]. The response rate for blood examination was 77.7%, and in the present study, we included only participants for whom blood samples were available [N = 36,329].
Data collection
The presence of CVDs, smoking, food consumption, physical activity, and mental-emotional state were self-reported. Body mass index [BMI], WC, waist-to-height ratio [WtHR], and blood pressure [BP] were measured by the surveyor. Blood samples were collected at the time of the interview to detect FBG or RBG and total cholesterol, low-density lipoprotein [LDL] cholesterol, and high-density lipoprotein [HDL] cholesterol levels.
We categorized participants as smokers if they currently smoked [daily or occasionally]. High-risk food was defined as sweet food and drinks, salty food, oily food, grilled food, preserved food, seasonings, soft drinks, energy drinks, and instant food/noodles. A “high-risk diet” was defined as consuming of three or more types of high-risk food at least once a day. Participants’ fruit and vegetable consumption was categorized as “inadequate” if intake was less than five portions/day according to the World Health Organization [WHO] standard [12]. Physical activity was defined based on the WHO Global Physical Activity Questionnaire [GPAQ] and categorized as “low” if participants did not meet the WHO standard for adequate physical activity [13]. Mental and emotional disorders were measured using the WHO 20-item self-reporting questionnaire [SRQ-20] [14], which was previously validated for the Riskesdas. We defined the presence of mental and emotional disorders as a score of 6 or above as it is already validated in the other study in Indonesia [with positive predictive value 60%, negative predictive value 92%] [15], and was used in the Riskesdas national report.
Participants’ anthropometric indices, namely, their weight, height, and WC, were measured using appropriate measuring tools. A digital weight scale with a precision of 100 g was used to measure weight; height was measured using a portable stadiometer with a precision of 0.1 cm, and WC was measured using a measuring tape with a precision of 0.1 cm at the midline between the inferior margin of the ribs and the superior border of the iliac crest. Participants with BMI ≥25 kg/m2 were considered “obese” [16], and a WC > 90 cm in men and > 80 cm in women was considered “high risk” [17]. In addition, the WtHR was also calculated, and a score > 0.5 was considered “high risk” [18].
BP was measured with a digital sphygmomanometer at least two times on the upper left arm while the patient was in a relaxed condition, and average systolic and diastolic BP was calculated to represent the participant’s BP. An average systolic BP of ≥ 140 mmHg and or an average diastolic BP of ≥ 90 mmHg, self-reported hypertension diagnosed by a physician, or the use of a BP-lowering medication was defined as “hypertension” [19]. Furthermore, for participants with hyperglycemia symptoms and RBG level ≥ 200 mg/dL or FBG level > 125 mg/dL, a self-reported diagnosis of diabetes or use of anti-diabetic medication was defined as “diabetes” [20]. FBG and RBG data were collected using a point-of-care test [POCT] glucometer. Lipid profiles [total, LDL, and HDL cholesterol levels] were measured in mg/dL. Blood samples collected from participants were sent to the National Laboratory in Jakarta to analyze lipid profiles using enzymatic assays, and total cholesterol ≥ 200 mg/dL, LDL cholesterol ≥ 160 mg/dL, and HDL cholesterol