|Year : 2018 | Volume
| Issue : 12 | Page : 60-68
Cardiovascular risk factors in a sampled cluster of geriatric Nigerians in a tertiary hospital in South-Eastern Nigeria: Implications for primary care geriatric cardiovascular health advocacy
Gabriel Uche Pascal Iloh1, John Nnaemeka Ofoedu2, Okechukwu Kalu Iro3
1 Department of Family Medicine, Federal Medical Centre, Umuahia; Department of Environmental Health Sciences, Faculty of Basic Medical Sciences, College of Medicine and Health Sciences, Abia State University, Abia, Nigeria
2 Department of Family Medicine, Federal Medical Centre, Umuahia, Nigeria
3 Department of Public Health, Federal University of Technology, Owerri, Imo, Nigeria
|Date of Web Publication||19-Nov-2018|
Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia
Source of Support: None, Conflict of Interest: None
Background: Cardiovascular (CV) risk factors tend to aggregate in geriatric population with variable distribution. These risk factors may act as alert signals for proactive geriatric CV health programs. Aim: This study was aimed at determining the frequencies of nonconstitutional CV risk factors in a sampled cluster of geriatric Nigerians in a tertiary hospital in South-eastern Nigeria. Setting and Design: This was a cross-sectional study carried out on a sampled of 280 geriatric Nigerians at the primary care clinic of Federal Medical Centre, Umuahia, Nigeria, between May 2012 and October 2012. Subjects and Methods: Geriatric Nigerians aged 60 years and above were screened for nonconstitutional risk factors of CV disease. The data collected included sociodemographic variables, metabolic, dietary, and behavioral risk factors using a structured, pretested, and researcher administered the questionnaire. Results: The top five most common CV risk factors were as follows: physical inactivity (67.1%), inadequate fruits consumption (65.7%), hypertension (48.2%), abdominal obesity (47.9%), and dyslipidemia (36.8%). Others were general obesity (31.1%), inadequate vegetable consumption (22.5%), diabetes mellitus (15.7%), habitual use of alcohol beverages (9.0%), habitual use of snuff (3.9%), and nonhabitual smoking of cigarettes (2.8%). Conclusion: This study has demonstrated that risk factors of CV disease exist among geriatric Nigerians in primary care with five most frequent being physical inactivity, inadequate fruits consumption, hypertension, abdominal obesity, and dyslipidemia. Screening geriatric Nigerians for modifiable CV risk factors should be integrated into geriatric primary health care in the study area.
Keywords: Cardiovascular risk factors, geriatrics, Nigeria, nonconstitutional, primary care
|How to cite this article:|
Pascal Iloh GU, Ofoedu JN, Iro OK. Cardiovascular risk factors in a sampled cluster of geriatric Nigerians in a tertiary hospital in South-Eastern Nigeria: Implications for primary care geriatric cardiovascular health advocacy. N Niger J Clin Res 2018;7:60-8
|How to cite this URL:|
Pascal Iloh GU, Ofoedu JN, Iro OK. Cardiovascular risk factors in a sampled cluster of geriatric Nigerians in a tertiary hospital in South-Eastern Nigeria: Implications for primary care geriatric cardiovascular health advocacy. N Niger J Clin Res [serial online] 2018 [cited 2020 Jul 11];7:60-8. Available from: http://www.mdcan-uath.org/text.asp?2018/7/12/60/245790
| Introduction|| |
Aging has been part of human history from time immemorial, and the proportion of the population that is elderly is increasing in both developed and developing nations., The population of the elderly is on the rise as life expectancy increases with implications for dependency and need for formal and informal care. The global increase in life expectancy is, therefore, one of the most important human achievements in the last century and is attributed to socioeconomic and technological development and advancement in health care., One of the challenges of increasing expectation of life in a population of people is the risk of developing component defining criteria for cardiovascular (CV) diseases which is related to the process of aging.,,
The relevance of constitutional and nonconstitutional risk factors in CV health has been a subject of intense global research in both developed,, and developing nations,,, and is reported as a critical element in risk assessment for global burden of diseases.,,,,, CV disease is relatively uncommon in the absence of its risk factors and rarely develops from a single risk factor but by constellations of mutable and immutable risk factors.,,,, However, it tends to develop insidiously due to the interactions of sociogenetic and behavioral risk factors. Even a little increase in one risk factor is very important when combined with other risk factors. The presence of CV risk factors in geriatric population does not signify that CV disease will develop and in its absence will not occur. Similarly, the presence of a combination of CV risk factors in the same geriatric person may be synergistically addictive or multiplicative and may be predictive of CV disease or prognostic that existing CV disease will worsen. The presence of multiple risk factors of CV disease is probably related to poor CV disease outcomes., Among the constitutional CV risk factors are biological factor of age, sex, race, familial predisposition and nonconstitutional variables of physical inactivity, excessive alcohol consumption, tobacco use, inadequate dietary fruits and vegetable consumption and cardiometabolic risk factors of hypertension, obesity, dyslipidemia, and diabetes mellitus.,,
Research studies have demonstrated the variability of CV diseases within and across different global populations.,,, In the global population in 1990, CV disease accounted for 28% of the global 50.4 million deaths and 9.7% of the 1.4 billion lost disability-adjusted life years (DALYs). In 2001, CV disease was responsible for 29% of all deaths and 14% of the 1.5 billion lost disability-adjusted life years and by 2030, when the population is expected to reach 8.2 billion, 32.5% of all deaths will be caused by CV disease. The aging population and sociobehavioral and nutritional changes probably motivate this trend.
The World Health Organization has recognized CV diseases as number one killer disease from noncommunicable diseases, and at least three-quarter of global mortality from CV-related noncommunicable diseases occurred in low- and middle-income Countries. Among the ten leading causes of global mortality are hypertension (13%), tobacco (9%), diabetes mellitus (6%), physical inactivity (6%), and obesity and overweight (5%). The “vision 2025” and target “25” by “25” of the World Health Organization is aimed at achieving a reduction of CV diseases by 25% by the year 2025. The emphasis is on targeting the modifiable risk factors and the diseases. With few years to the attainment of the year 2025, the impact of program for CV diseases is variable globally with favorable effects reported in advance nations.
In Nigeria Africa, the national noncommunicable disease survey in Nigeria and recent research reports on cross-sections of the Nigerian population,,,,,,,,,,,,,,, have demonstrated that the burden of CV diseases is increasing in all parts of Nigeria. Available research studies in the Nigerian subregion on CV risk factors did not focus on geriatric patients in primary care settings but on general population in hospitals and communities,,,,,, and other specific population groups such as hypertensive patients, Priests, company executives, traders, health workers, university staff, and primary care patients. Since advancing age is a proxy indicator of the need for CV health and other diverse care, the detection of CV risk factors in geriatric Nigerians should constitute a prelude to interventional control measures to mitigate adverse CV events particularly in a primary care setting. As Nigerian geriatric population continues to undergo nutritional, epidemiological, ecological, demographic and lifestyle transitions, a research on the frequencies of CV risk factors is needed for proactive clinical and public health action. The present study was therefore carried out to provide data on the frequencies of nonconstitutional CV risk factors among geriatric Nigerians in a primary care clinic of a tertiary hospital in South-eastern Nigeria.
| Subjects and Methods|| |
This was a descriptive primary care clinic-based study carried out on 280 geriatric Nigerian patients from May 2012 to October 2012 at the Department of Family Medicine of Federal Medical Centre, Umuahia, South-eastern, Nigeria.
Umuahia is the capital of Abia State, Nigeria. Abia State is endowed with abundant mineral and agricultural resources with a supply of professional, skilled, semi-skilled, and unskilled workforce. Economic and social activities are low compared to industrial and commercial cities such as Onitsha, Port Harcourt, and Lagos in Nigeria. Until recently, the capital city and its environ have witnessed an upsurge in the number of banks, hotels, schools, markets, industries, junk food restaurants in addition to the changing dietary and social lifestyles.
The inclusion criteria were Nigerian patients aged 60 years and above who gave informed consent for the study while the exclusion criteria were critically ill geriatric patients and those who had ascites and physical deformities affecting the spine and/or the limbs who could not stand for height and weight anthropometric measurements.
Sample size was estimated from the formula for calculating minimum sample size for descriptive studies when the population is equal or more than 10,000; N = Z2 pq/d2 where N = Minimum sample size, Z = Standard normal deviation usually set at 1.96 which corresponds to 95% confidence interval, P = Proportion of the population estimated to have a particular characteristic. Due to the multivariate nature of CV risk factors, the authors assumed that 50% of the geriatric patients would have at least one of the CV risk factors at 95% confidence level and 5% margin of error. This assumption was likely to maximize the estimated variance and provided a sample size that was precisely representative for the study population., This gave a sample size estimate of 384; thus, q = 1.0-p = 1.0–0.5 = 0.5, d = degree of accuracy set at 0.05. Hence N = (1.96)2 × 0.5 × 0.5/(0.05)2. Therefore, n = 384.
Since the previous annual geriatric patients attendance at the primary care clinic of the hospital was <10,000. In determining the sample size for the population <10,000 using the estimated previous biannual population of geriatric patients at the primary care clinic of 1000 and substituting in the formula nf = n/1 + (n/N) where n = 384; n = 1000. Thus, nf= 277. However, selected sample size of 280 geriatric patients was used for the study.
The sampling technique involved consecutive selection of every geriatric patient who registered to see the clinicians on each consulting day during the study and who met the inclusion criteria.
Metabolic risk factors were determined by anthropometric estimation of weight and height, waist circumference (WC), clinical evaluation of blood pressure, and laboratory measurement of fasting plasma glucose. The weight was measured in kilograms with the geriatric patient standing bare feet in their minimal clothing while the height was measured barefooted and without head-gear or cap stood against the stadiometer on the weighing scale with the Achilles, gluteus, and occiput touching it. The body mass index was estimated by dividing measured weight in kilograms by the height in meters squared. The WC was measured using flexible nonstretchable tape in a geriatric patient who stood erect with arms at the side and feet together. The iliac crest and lower rib cage were first identified by palpation. The WC was taken as the midpoint between the lower border of the lower rib cage and iliac crest in a horizontal plane parallel to the floor.
The blood pressure of the geriatric patient was measured using the auscultatory method with standard mercury in glass Accuson sphygmomanometer. The plasma glucose was determined after an overnight fast between 8.00 and 10.00 h using venous plasma by glucose oxidase method. Repeat fasting plasma glucose was done for those who had abnormal fasting plasma glucose test result on the next scheduled clinic visit.
The body mass index of ≥30 kg/m2 was taken as the definition of general obesity. Abdominal obesity was defined using WC ≥94 cm for men and ≥80 cm for women while hypertension referred to the systolic and/or diastolic blood pressures of ≥140/90 mmHg or documented use of antihypertensive medications in a previously diagnosed person with hypertension. Diabetes mellitus was defined based on the presence of a personal history of diabetes mellitus and/or the patient was on anti-diabetic medications or for patients without personal history of diabetes mellitus, fasting venous plasma glucose of ≥126 mg/dL which was confirmed by a repeat test on second clinic visit.
Data collection instrument was adapted from the generic WHO-STEP wise instrument approach to surveillance of chronic noncommunicable diseases risk factors and was modified to suit Nigeria environment through robust review of relevant literature on CV risk factors.,,,,,,,,,,,,,,,,,,,,,, The basic demographic factors of age, sex, marital status, education, and occupation were obtained.
The behavioral risk factor of physical activity was assessed by inquiring how many times the geriatric patient was engaged in physical activities in the previous 7 days. Those who engaged in activities that cause a moderate or large increase in breathing or heart rate for ≥30 min for ≥3 days/week were considered physically active while the level of activity below this was considered physical inactivity. Alcohol consumption was assessed in the geriatric patients in the week preceding the study and classified as habitual use, nonhabitual use, ever use, and never use for geriatric patient who consumed any type of alcoholic beverages daily or occasionally in the week preceding the study, geriatric patient who used alcohol previously and stopped, and those who had never used alcohol in their lifetime, respectively. Similarly, tobacco use was evaluated among the geriatric patient with respect to the use of cigarettes and snuff in the lifetime and classified as habitual use, nonhabitual use, ever use, and never use for geriatric patient who used any type of tobacco daily or occasionally in the week preceding the study, geriatric patient who smoked cigarette or used snuff previously and stopped and those who had never smoked cigarette or used snuff in their lifetime, respectively. Dietary consumption of fruits and vegetables among the geriatric patients was assessed in the previous 7 days. Geriatric patients who had ≥3 servings/week had adequate dietary fruits and vegetable consumptions respectively while those who had <3 servings/week had inadequate dietary fruits and vegetable intake.
The pretesting of the questionnaire was done internally at the primary care clinic of the hospital using ten middle-aged patients. The pretesting of the questionnaire lasted for a day. The individuals for the pretesting of the questionnaire were selected haphazardly from the clinic. The pretesting was done to find out how the questionnaire would interact with the study individuals and ensured that there were no ambiguities. The questionnaire instrument was interviewer-administered and administered once to each eligible respondent.
The authors defined geriatric patients as those aged 60 years and above. CV risk factors refer to antecedent condition(s) whose presence is (are) positively associated with an increased probability that CV disease will develop later. Nonconstitutional CV risk factors are the modifiable risk factors and included metabolic risk factors of hypertension, obesity, dyslipidemia and diabetes mellitus and behavioral risk factors of physical inactivity, excessive alcohol use, tobacco use, inadequate fruits, and vegetable consumption. Primary care is the care provided by physicians specifically trained for comprehensive first contact and continuing care for undifferentiated patients including early detection and management of the patient, health promotion, and maintenance.,
The results generated were analyzed using software Statistical Package for Social Sciences version 13.0, Microsoft Coperation Inc., Chicago, IL, USA, for the calculation of percentages for categorical variables and mean for continuous data.
Ethical certification was obtained from the Health Research and Ethics Committee of the hospital.
| Results|| |
A total of 280 geriatric patients were studied. The age of these patients ranged from 60 to 86 years with a mean age of 67 ± 3.4 years. There were 102 (36.4%) males and 178 (63.6%) females with male to female ratio of 1:1.7. Other demographic profiles of the study population are shown in [Table 1].
The top five most frequent CV risk factors were physical inactivity (67.1%), inadequate fruits consumption (65.7%), hypertension (48.2%), abdominal obesity (47.9%), and dyslipidemia (36.8%). Others were general obesity (31.1%), inadequate vegetable consumption (22.5%), diabetes mellitus (15.7%), habitual use of alcohol beverages (9.0%), habitual use of snuff (3.9%), and nonhabitual smoking of cigarettes (2.8%) [Table 2].
|Table 2: Frequency of cardiovascular risk factors among the study participants|
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| Discussion|| |
This study has shown that 67.1% of the geriatric patients were physically inactive and physical inactivity was the most frequent CV risk factor among the study population. The finding of this study has buttressed the report that more than 50% of the global population are physically inactive and physical activity decreases with advancing age. The higher proportion of physical inactivity among the geriatric population could be a reflection of structural and physiological changes associated with aging., With advancing age, personal, instrumental, and domestic activities of daily living decrease with the resultant effect on metabolic homeostasis and cardiorespiratory fitness., There is also a growing evidence of the detrimental impact of physical inactivity on CV system as well as the beneficial effects of physical activity on CV health such as reduction of blood pressure, improve glucose and lipid homeostasis, enhancement of endothelial function, fibrinolysis, and parasympathetic autonomic tone., Although physical inactivity is a worldwide health problem, it occurs disproportionally higher in geriatric population particularly in countries that are undergoing rapid socioeconomic, technological, and epidemiological transitions. Of great concern in the study area is the perception of physical inactivity as a sign of affluence among the populace., More worrisome is the role of information and communication technologies and modern means of transport on activities of daily living among the elderly persons. These technological devices and facilities have reduced transport time-related physical activity which involves energy expenditure among the elderly population. More so, in the study area is the reduction of domestic, farming and other community-related activities among the geriatric population due to changes in the family ecogeography and function resulting from the presence of children, grandchildren, great-grandchildren, and extended family relatives who assist their elderly parents and grand-parents in household and community chores and subsistence farming. However, in the absence of dedicated and functional geriatric CV health program in Nigeria, primary care physicians should screen elderly patients for physical activity profile during a clinical encounter to institute appropriate health promotion and maintenance programs for the physically inactive. A physical activity regimen tailored to the geriatric population in the study area to improve CV health will be remarkably beneficial as some physical activity is better than no physical activity, and additional CV benefits occur with more physical activities. Physical activity is therefore not an activity that anybody outgrows, and geriatric patients who have been physically inactive should start physical activity as there is a physical activity for everyone.
Inadequate dietary consumption of fruits had second highest frequency among the geriatric patients. The finding of a higher frequency of inadequate fruits consumption among the study population could be a reflection of the Nigerian family diet in which fruits are eaten by choice and by chance as snacks while dietary vegetables are predominantly served as part of the daily meals., This finding is in tandem with reports of changing dietary pattern in Nigeria characterized by consumption of nutrient deficient and calorie-dense foods., Research studies have shown that adequate consumption of fruits gives larger CV health benefits than inadequate consumption and the relevance of inadequate fruits consumption as a modifiable risk factor of CV disease has been the focus of several dietary guidelines targeting reduction of CV-related diseases, and adequate consumption of fruits is fast becoming the norm rather than exception particularly in developed nations., The increasing demand for dietary fruits consumption is, therefore, a global nutrition-related phenomenon and a primary care clinic concern due to the significant interplay between CV disease and human dietary fruit consumption. The physio-biochemical mechanisms responsible for the CV benefits of adequate fruits consumption has been elucidated in biomedical literature as regards its antioxidant and other diverse anti-inflammatory properties. Identifying CV risk factors particularly those related to inadequate fruits consumption which are amenable to effective interventions, therefore, avails greater opportunity for early diet-related health promotion particularly in resource-constrained environment where health-care seeking behavior and utilization are largely driven by the need for curative services rather than imperative for proactive preventive care. Primary care physicians should, therefore, explore the level of consumption of dietary fruits because consumption of any dietary fruit is better than none and geriatric patients who have inadequate consumption of dietary fruits need to start as part of recommended daily dietary menu.
Hypertension was the third-most common CV risk factor among the study population. The frequency of hypertension of 48.9% in this study is higher than the hypertension prevalence range of 8.0%–46.4% reported in a systematic review of literature on the prevalence of hypertension in adult Nigerian Africans. This finding is in consonance with reports that hypertension is the most common cardio-metabolic disease among geriatric population in the study area., However, hypertension is not only a pathological medical condition itself but may co-exist with other risk factors of CV disease among the elderly population., Hypertension and the biologic factor of age, therefore, are related to each other patho-biologically and pathophysiological, and their co-existence poses management challenges for geriatric health care particularly in resource-poor environment of Nigeria.,, The pathogenetic mechanisms underlying the relationship between age and hypertension are linked with arteriosclerosis and atherosclerosis characterized by endothelial injury and dysfunction, and deposition of low-density lipoprotein cholesterol amidst other retinues of structural and functional pathological processes. These cascades of pathologic events are central to the initiation and progression of arteriosclerosis and atherosclerosis in the elderly population. Although not every geriatric patient has hypertension, their risk of developing hypertension is higher. The increasing number of elderly hypertensives in Nigeria could add to the rising incidence of CV diseases. In this regard, primary care clinicians should take appropriate steps to detect hypertension among elderly population with progressively senescence CV system. It is, therefore, an ethical imperative to identify such geriatric Nigerians as early as possible since the protracted natural history of hypertension makes it an ideal target for proactive preventive care. Obtaining the history of hypertension among the geriatric patients should inform the need to assess for other CV risk factors to reduce their interactive and multiplicative effects. The earlier the primary care oriented interventions are started for the geriatric population, the more likely it is to be beneficial.
Abdominal obesity was the fourth-most common CV risk factors among the study population. The finding of this study has buttressed the reports that abdominal obesity is an issue of phenomenal medical importance in Nigeria, particularly in geriatric population., Of great concern in Nigerian, sociocultural environment is that body image at the level of abdominal obesity is not always perceived as a health risk and local perception of abdominal obesity as a feature of good living and affluence is common.,,, Although fats act as a storage organ for excess calories, its abdominal distribution is however associated with increased risk of CV diseases., Abdominal obesity among the elderly population can, therefore, have deleterious effects on their biophysical health and can trigger other acute and chronic metabolic complications of abdominal obesity., The finding of this study, therefore, creates a pedestal for the geriatric patients in the study area to understand abdominal obesity as a health risk not an indication of prosperity. It is therefore pertinent to detect early the emergence of abdominal obesity especially among the geriatric population as early intervention may alter morbidity endpoints. Educating geriatric patients on the relevance of waist size measurement and its interpretation should be integrated as part of geriatric patient health education during clinical encounter in primary care. Screening geriatric patients with abdominal obesity for other CV risk factors needs to be at initial clinical encounter as the development and damage by abdominal obesity start even before the diagnosis is made. This will help to improve the quality of CV health care rendered to geriatric patients.
Dyslipidemia is the fifth-most common CV risk factors among the study population. Pathogenetically, the underlying mechanism of geriatric dyslipidemia is complex and has clusters of inter-related constitutional and nonconstitutional factors which could predict the development of CV disease.,,, While the age is a constitutional CV risk factor, dyslipidemia is largely a nonconstitutional CV risk factor, and geriatric dyslipidemia could, therefore, add to other driving forces responsible for increasing predisposition to CV disease among the elderly population., Bio-physiologically, aging process is associated with reduced lipid metabolism, increase in cholesterol gradient leading to sequestration of cholesterol into the abdominal region and reduction in the ability of the body to shift cholesterol from abdominal tissues to the liver. More so, in aging there is a relative decrease in muscle mass with increase in fat mass and a decrease in muscle mass may result in concurrent decrease in lipid metabolism. Furthermore, aging is characterized by progressive redistribution of fat stores from peripheral sites to the intra-abdominal region and the accumulated visceral abdominal fats are highly lipolytic and could contribute to geriatric dyslipidemia. The earlier dyslipidemia is identified among the geriatric patients, the better the prospect of mitigating its impact on geriatric CV health., Establishing a baseline lipid profile during clinic visits and checking them appropriately during subsequent visits can provide the primary care physicians an excellent means of educating the geriatric patients on the need for lifestyle modification that will help to establish a culture of healthy living.
Implications of the study
The health of Nigerian geriatric population is in a state of transition characterized by lifestyle changes that promote the development of CV diseases. The lifestyle transition is rapidly changing in Nigeria particularly among the elderly population moving from traditional diets and more active lifestyles to westernized diet and more sedentary living which have implications for CV disease. The on-going modernization of lifestyles in Nigeria offers the geriatric population the opportunity of not only socioeconomic growth but also clustering of risk factors of CV disease and this carries great concern for the future.
Although there are many constraints to the control of CV diseases among general and specific high-risk groups in Nigeria, appropriate interventional measures are urgently needed to prevent the early emergence of CV diseases on geriatric Nigerians, and this requires research on CV risk factors particularly for the vulnerable group such as elderly persons. This research study on the risk factors of CV disease among geriatric Nigerians would stimulate the need for wider research priorities and other interventions that will assist in the quest for CV health advocacy for geriatric population who are living in the resource-limited environment of the study area.
Limitations of the study
The limitations of this study are recognized by the researchers. First and foremost, the study was carried out on geriatric patients accessing care from the primary care clinic of the hospital. Hence, the results of this study may not be general conclusions regarding geriatric patients attending surgical and medical outpatient clinics of the hospital. Second, the sampled population was drawn from hospital attendees in the study area as only geriatric patients who presented to the primary care clinic of the hospital were studied. Thus extrapolation of the results of this study to the entire geriatric population should be done with caution because the findings may not be a true representation of what may be obtained in the community. Third, this study was dependent in part on self-reported socio-behavioral factors, and this could have led to recall bias and socially desirable responses. Fourth, the assessment for the behavioral risk factors of alcohol consumption, tobacco use and dietary consumption of fruits and vegetables were not quantitative. Finally, this study was not an all-inclusive study on CV risk factors but on some selected nonconstitutional risk factors such as hypertension, obesity, diabetes mellitus, dyslipidemia, physical inactivity, alcohol and tobacco use, and inadequate consumption of dietary fruits and vegetables.
| Conclusion|| |
This study has demonstrated that risk factors of CV disease exist in variable frequencies among geriatric Nigerians in primary care with five most frequent being physical inactivity, inadequate fruits consumption, hypertension, abdominal obesity, and dyslipidemia. Screening geriatric Nigerians for nonconstitutional CV risk factors should be integrated into geriatric healthcare and should be a compelling health priority in primary care settings particularly in resource-poor environment where there are limited options for geriatric well-being and wellness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]