Cardiovascular disease (CVD) is the leading cause of death among the noncommunicable diseases (NCDs). By reducing the prevalence of behavioral (CVD) risk factors (tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol), a large percentage of CVDs and other NCDs can be prevented [
According to the National NCD Risk Factors Survey in 2007, the prevalence of diabetes mellitus (DM) was 14.3%, hypertension (HTN) was 38.2%, and high cholesterol level was 40.6%. In addition, the overall prevalence of obesity was 36.3% and 32.9% overweight. Furthermore, 62% reported daily intake of vegetables, while only 49.6% reported daily intake of fruits. Around 57.1% reported that they do not engage in any physical activity at leisure time. Finally, the overall prevalence of smoking was found to be 19.9% (AL Sayyad J., MOH, Bahrain, 2010).
The majority of the epidemiological studies from the region were descriptive and among samples of subjects or volunteers from the general population with little emphasis on the workers in their workplaces. The employees in any community represent the main workforce and their quality of life, health awareness, and adoption of healthy behaviors reflect on the overall productivity, economic growth, and the disease burden. Regardless of the study sample, the overall prevalence of CVD risk factors is high and primary and secondary preventions and interventions are vital.
In a cross-sectional study done in Iran about CVD risk factors, the overall prevalence of overweight among men was 36.6% and 35.9% among women. 11.2% of men and 28.1% of women were obese. The mean BMI, waist circumference (WC), and waist hip ratio increased with age up to 65 years. The total serum cholesterol (TC), triglycerides (TG), and 2-hour postload plasma glucose increased with BMI and WC in both sexes [
Weqaya is a population-wide CVD screening program in Abu Dhabi, UAE, in which self-reported indicators, anthropometric measures, and blood tests were used to screen 138 adults aged 18 years or older. Participants mean age was 36.82 years; 43% were men. Risk factors prevalence rates were as follows: obesity 35%, overweight 32%, central obesity 55%, DM 18%, pre-DM 27%, dyslipidemia 44%, and HTN 23.1%. In addition, 26% of men were smokers, compared with 0.8% of women. Age standardized DM and pre-DM rates were 25% and 30%, respectively, and age standardized rates of obesity and overweight were 41% and 34% [
A study was conducted to determine the prevalence of CHD risk factors among 159 male university students in Dammam City, Saudi Arabia. It was found that 28.9% of the University students do not practice any type of physical activity. Moreover, 37.7% and 46.5% of them were watching TV and using computer for 14 hours and more, respectively. About 19% of them were current smokers. 24.5% were overweight, 11.9% were obese, and 10.7% were severely obese based on BMI and waist-hip ratio. The mean systolic and diastolic blood pressure readings of students were 122.8 mmHg and 71.5 mmHg, respectively [
The research into the epidemiology of physical activity in Saudi Arabia and neighboring countries is sparse. From a brief review of published data about the level of physical activity in Saudi Arabia from 1990 to 2004, around 8 studies were found. Across the studies, the total rate of inactivity ranged from 43.3% to 99.5%. Only 2 of the studies included data for both males and females. Their data indicated that females were much less active than males [
The high prevalence of CVD in the region seems to be communal. This descriptive study will determine the prevalence in the Kingdom and provides a base for future descriptive and analytical studies which will aid in planning and provision of primary and secondary CVD prevention services and population based health promotion programs. Studying CVD risk factors among the workers will lead to recommendations that can motivate employers and policy makers to put CVD prevention among their priorities. In addition, it will enforce legislations in tobacco control and food labeling and help in promotional activities for the employees.
A cross-sectional work-site based survey was used to describe the prevalence of some of CVD risk factors among government employees in Bahrain.
The sample size was calculated to ensure representation of the population and was estimated to be 1139 employees as the total number of the government employees was unknown before the study.
All the adult government employees of both genders and who participated in the health campaign during the study period in Bahrain were included in the sample. Pregnant women and cardiac patients were excluded from the sample. If a particular machine, such as the near patient testing device (LDX system for testing blood for lipids and the carbon monoxide monitor), is defaulted during a planned campaign, data was excluded from the analysis and the related data was considered missing.
Data was collected by face-to-face interviews of participants by a comprehensively trained team and filling of standardized bilingual (Arabic and English) questionnaires. The team was composed of medical record staffs, nurses, laboratory technicians, doctors, a health promotion specialist, a driver, and a nutritionist. Structured interviews were conducted with the participated employees in designated rooms in each workplace during working hours. Standardized serially numbered forms for the participant employee data were used. The forms were composed of
A well-calibrated sphygmomanometer and digital blood pressure machines were used for blood pressure measurements, measuring tapes for the WC, weighing scales for the waist circumference (WC), weighing scales for the Wt., HT., and BMI measurements. The Cholestech L.D.X System consists of a compact, portable,lightweight (<1 Kg) electronic analyzer and a series of unique, single-use disposable casettes. The L.D.X System delivers the ability to measure a complete lipid profile and glucose and it does it all in 5 minutes per test cassette. The system is evaluated by the UK medical devices Agency. Moreover, Carbon Monoxide (CO) measurements were taken for smokers using a device called a CO monitor.
For blood pressure measurement, participants’ conditions were ensured to follow the BP measurement guidelines including
The equipment used for the cholesterol near patient testing includes single use safety lancets, cholesterol testing cassettes, septic wipes, sterile gauze, capillary tube to collect blood, gloves, hand wash, papers bin, and hypoallergenic Elastoplast.
A standardized procedure was as followed including wearing gloves, ensuring hand wash, using the participants’ ring or index finger after warming it for the blood to flow better, wiping it with antiseptic, and drying it with gauze. The participant’s finger then pricked after informing and reassuring. The first drop of blood was wiped away with gauze and a capillary tube was used to suck up blood from the finger (the participant was asked to hold the hand with the fingers pointing down to help with the blood flow). Sometimes the fingers have to be squeezed slightly to get the blood out, but not too much so that the quality of blood sample is not affected by contaminating it with the tissue fluids or skin cells. The blood drop was put into the cassette. When the test is conducted, participant's results were recorded on their questioners and used sharp materials, used L.D.X cassettes with the soiled materials were kept directly in sharp containers to be handled as per infection control guidelines. The machine needed to be regularly calibrated and quality assured by the providing company. Appropriate training was given on use of the machines and measurements tools in use. All users had Hepatitis B cover.
Ethical approvals, data protection, and confidentiality were anticipated and dealt with in a professional manner. However, there were no written consents as the study was from a health survey in which the employees participated after verbally being informed about the need for CVD risk factors data among employees. Ministry of health and a pharmaceutical company funded the health campaign. The funder from any pharmaceutical company was not included in the data analysis or collection.
The data were entered and analyzed using descriptive and inferential statistics where appropriate. Descriptive statistics were used to summarize the data. Means and standard deviations were used to represent quantitative variables and percentages or proportions for categorical variables. In addition, the computer programs STATA and Excel were used to tabulate frequencies and produce graphs. The response rate was calculated and was around 99.9%.
The majority of the participated employees were Bahraini (93.9%). The mean age of the participants was 39.1 years, with 43.7% women and 56.3% men. The majority had graduated from colleges and 27.2% completed their basic education. Almost 80% of the participants were staff and 13.6% were in the management.
The participants’ distribution according to some behavioural risk factors was demonstrated in Table
The behavioural risk factors of the participants (employees).
Number |
|
Males | Females | Total number (%) |
---|---|---|---|---|
1 | Tobacco use |
|
||
Yes |
|
|
182 ( |
|
No |
|
|
955 ( |
|
|
||||
2 | Type of tobacco |
|
||
Cigarette | 111 ( | |||
Shisha | 43 ( | |||
Cigarette and shisha | 27 ( | |||
Not asked | 2 (0.6) | |||
|
||||
3 | Carbon monoxide (CO) measurements among smokers (ppm) |
|
||
0–6 nonsmoker | 111 ( | |||
7–15 low dependence | 38 ( | |||
>15 strongly dependent | 34 ( | |||
|
||||
4 | Physical activity |
|
||
Yes | 287 |
|
444 ( | |
No | 219 |
|
460 ( | |
|
||||
5 | Physical activity frequency* |
|
||
Yes | 320 ( | |||
No | 520 ( | |||
Not asked | 3 (0.3) | |||
Not applicable | 47 (5.3) | |||
|
||||
6 | Fruits and vegetables intake |
|
||
Yes | 683 (75.4) | |||
No | 220 (24.3) | |||
|
||||
7 | Fruits and vegetables servings per day** |
|
||
1-2/day | 549 (81) | |||
3-4/day | 94 (13.9) | |||
≥5/day | 33 (4.9) | |||
Not asked | 2 (0.2) |
Among 905 who responded to the physical activity questions, 50.8% were not physically active. Sufficient physical activity was defined as engaging in moderate-intensity physical activity or walk for at least 30 minutes 5 days per week or 20 minutes of vigorous activity 3 days/week.
Among 903 participants, 75.4% were eating fruits and vegetables as part of their diet. Among those, 81% were found to eat 1-2 servings of fruits and vegetables per day. Only 4.9% were found to be eating ≥ 5 servings per day of fruits and vegetables.
Eating ≥ 5 servings of fruit and vegetables are considered protective from cardiovascular event.
Table
The physical measurements of the participants (employees).
Number | Characters | Males | Females | Total number (%) |
---|---|---|---|---|
1 | Body mass index (BMI) in Kg/m2 |
|
||
Underweight (<18.5 Kg/m2) |
|
|
10 (0.9) | |
Normal weight (18.5–24.9 Kg/m2) |
|
|
235 ( | |
Overweight (25–29.9 Kg/m2) |
|
|
452 ( | |
Obese (≥30 Kg/m2) |
|
|
440 ( | |
|
||||
2 | Waist circumference (males) |
|
|
|
<94 cm | 186 | 186 (37.6) | ||
≥94 cm | 309 | 309 ( | ||
|
||||
3 | Waist circumference (females) |
|
|
|
<80 cm | 45 | 45 (11.4) | ||
≥80 cm | 350 | 350 ( | ||
|
||||
4 | Systolic blood pressure (sbp) |
|
||
<120 mmHg |
|
|
413 ( | |
120–139 mmHg |
|
|
477 ( | |
≥140 mmHg |
|
|
247 ( | |
|
||||
5 | Diastolic blood pressure (dbp) |
|
||
<80 mmHg |
|
|
502 (44.2) | |
80–89 mmHg |
|
|
369 (32.5) | |
≥90 mmHg |
|
|
266 ( |
The prevalence of reported hypertension among the participants was 36.9% that included the participants who were not on treatments and those who were on treatment. Further hypertension data analysis by gender is in Table
The body mass index (BMI) measurements demonstrated that 39.7% of the participants were overweight (BMI 25–29.9 Kg/m²) and 38.7% were obese (BMI ≥ 30 Kg/m²). The overall prevalence of overweight and obesity among the participants is 78.4% as shown in Figure
The prevalence of cardiovascular disease risk factors among the participants (employees).
Table
The biochemical measurements of the participants (employees).
Number | Characters | Males | Females | Total number (%) | Number |
---|---|---|---|---|---|
1 | Random blood glucose (RBG) |
|
|
||
≤6 mmol/dL |
|
|
930 ( | ||
≥6.1 mmol/dL |
|
|
182 ( | ||
|
|||||
2 | Total cholesterol (TC) |
|
|
||
≤5.1 mmol/dL |
|
|
836 ( | ||
≥5.2 mmol/dL |
|
|
267 ( | ||
|
|||||
3 | Low density cholesterol (LDL) |
|
|
||
<2.6 mmol/dL |
|
|
628 ( | ||
2.6–3.3 mmol/dL |
|
|
269 ( | ||
3.36–4.1 mmol/dL |
|
|
92 ( | ||
4.14–4.89 mmol/dL |
|
|
14 (1.4) | ||
≥4.92 mmol/dL |
|
|
3 (0.3) | ||
|
|||||
4 | High density lipoprotein (HDL) |
|
|
||
<1.03 mmol/dL | 400 (64.1) |
|
532 ( | ||
1.03–1.54 mmol/dL | 184 (29.5) | 266 (53.6) | 450 ( | ||
≥1.55 mmol/dL | 40 (6.4) | 98 (19.8) | 138 ( | ||
|
|||||
5 | Triglycerides (TG) |
|
|
||
≤1.69 mmol/dL | 621 ( | ||||
≥1.7 mmol/dL | 502 ( |
Comparison of some risk factors between genders among the participants.
Number | Variable | Male number (%)/Mean (SD) | Female number (%) | Total/(95% CI) |
|
---|---|---|---|---|---|
1 | Tobacco use | 162 (89) | 20 (10.99) | 182 (100) | 0.001* |
|
|||||
2 | BMI | Mean 29.1 (5.3) | Mean 29.3 (5.98) | The mean BMI was 0.17 kg/m2 higher among females |
<0.6** |
|
|||||
3 | Physical inactivity | 219 (47.6) | 241 (52.4) | 460 (100) | 0.001* |
|
|||||
4 | Systolic blood pressure (sbp) | 127.4 (17.1) | 118.1 (17.1) | The mean sbp was 9.2 mmHg higher among males |
<0.001** |
|
|||||
5 | Diastolic blood pressure (dbp) | 80.9 (11.1) | 74.3 (11.5) | The results show the mean dbp was 6.6 mmHg higher among the males |
<0.001** |
|
|||||
6 | High density lipoprotein (hdl) | 0.98 (0.41) | 1.3 (0.4) | The mean high density lipoprotein was 0.3 mmol/L higher among the females |
<0.001** |
The total cholesterol was tested in 1104 participants with 24.2% having levels ≥ 5.2 mmol/dL.
Among the 1007 tested participants, the majority (62.4%) had their LDL levels < 2.6 mmol/dL. 26.8% of them had it between 2.6 and 3.3 mmol/dL, while only 10.8% had their LDL levels above 3.3 mmol/dL.
Among the 1121 participants who were tested for HDL-C, 47.55% had their HDL levels ≤ 1.03 mmol/dL, while only 12.31% had it ≥ 1.55 mmol/dL.
Further HDL results levels analysed by gender are discussed in Table
Figure
The distribution of composite cardiovascular disease risk factors among the participants (employees).
As per Table
The overall prevalence of overweight among the participants was 39.8% with prevalence among the males of 42.9% and 23.6% among females. The overall prevalence of obesity among the participants was 38.7% with 36.97% prevalence among the males and 40.9% among females. The mean values of BMI between males and females were compared using the unpaired
The overall prevalence of physical inactivity among the participants was 50.8% with aprevalence of 60.6% among females and 43.3% among males. There was a significant difference in physical activity among gender, with 64.6% of the physically active being males, while only 35.3% of them were females (
The prevalence of reported hypertension among the participants was 36.9% and that included the participants who were on and not on treatments. The prevalence of hypertension based on systolic blood pressure readings is 21.7% and 23.4% based on diastolic blood pressure readings.
The prevalence of hypertension based on systolic blood pressure readings among males was 27.5% and 14.3% among females. The mean systolic blood pressure was 9.2 mmHg higher among the males, and this difference was statistically significant (
The prevalence of hypertension based on diastolic blood pressure readings among males was 31.4% and 13.1% among females. The results show the mean diastolic blood pressure was 6.6 mmHg higher among the males, and this difference was statistically significant (
The prevalence of low HDL level (<1.03 mmol/dL) among the male participants was 64.1% while it was 26.6% among the females. The results show the mean high-density lipoprotein was 0.3 mmol/L higher among the females, and this difference was statistically significant (
There is an emerging increase in the prevalence of CVD risk factors in Middle East. Age-standardized death rates per 100000 population in Kingdom of Bahrain by gender and cause were 68.8 for Ischaemic Heart Disease (IHD) and 28.2 for cerebrovascular disease [
While conducting this study there were some problems met with deciding the inclusion and exclusion criteria. There were some difficulties in getting biochemical results of some participants due to high triglyceride levels, which lead to incomplete or missing data.
As data was collected from different workplaces, at intervals, there may be an issue with the reliability and consistency of the data based on the blood pressure, height, and weight measurements. Some information may be missing from the data sets or may have been erroneously entered. Moreover, since it is an observational study design, there was no control over the participants’ characteristics with possible major sources of bias such as sampling, measurements, volunteering, and information. Analyzing the blood pressure and low-density lipoprotein levels data was difficult as the cutoff points were different across guidelines. Some variables did not show normally distributed. That needed some experience for the decision to report the mean or the interquartile range.
Insufficient physical inactivity is associated with 20%–30% increased risk of all-cause mortality [
Numerous studies have demonstrated the association between the physical inactivity “westernization” (a change from traditional lifestyle, one that incorporates manufactured foods and sedentary employment) and obesity. Physical inactivity can lead to prediabetes, diabetes, hypertension, and dyslipidemia [
Although the employees recognize the overall health benefits of regular and sufficient physical activity, the CVD associated benefits are not well recognized. Moreover, the employers were not sufficiently promoting this healthy behavior among their employees during their working hours. The employees are not able to be physically active after their working hours because of their roles in the family or community. Similarly, a survey of NCD related risk factors of Iranian adults in 2007 demonstrated a linear association between the number of metabolic abnormalities and lower levels of physical activity [
Smoking is a very common avoidable risk factor for CVD. There are about one billion current smokers in the world, and the prevalence of daily smoking varied across WHO regions [
Low fruits and vegetables intake is one of the dietary behaviors that were linked with increased risk for CVD (Mendis et al., 2010). Although this study demonstrated quite high intake of fruits and vegetables among the participants, only a very small percentage was taking more than 5 servings per day that is considered cardioprotective from the trials. Similar findings were reported from the national survey. According to Gaziano, the dietary pattern changes in the Middle East were shifted from traditional fiber rich and low fat into low fiber, high sugar content with decline in fruits and vegetables intake and high fat. The fast and preserved foods are more abundant and the fat intake has risen [
The oil rich countries such as Kuwait, Qatar, Saudi Arabia, United Arab Emirates, Bahrain, Oman, and Yemen are characterized by high intakes of red meat, carbohydrates, and sugar [
Obesity prevalence is rising in the world. It was associated with the major CVD risk factors and has adverse metabolic effects on lipids, blood glucose, and blood pressure [
The prevalence of obesity in the Middle East as a whole was found to be higher in women than in men, but the rates of obesity were similar in both sexes [
In Isfahan Healthy Heart program, 3694 participants were measured. There was a 35.9% prevalence of overweight among women and 28.1% obesity [
This study revealed 62.4% of males to have abdominal obesity (WC ≥ 94 cm) and 88.6% of females (WC ≥ 80 cm). Although studies using waist circumference as an indicator or measure of obesity in this region are scanty, the high prevalence of central obesity in both genders is understandable with the overall high prevalence of obesity and physical inactivity. The prevalence of metabolic syndrome was 19.8% in women and 63% in obese women. In men, corresponding values were 3.7%, 18.0%, and 40.1% as was demonstrated by [
Hypertension is a major CVD risk factor. This study showed similar overall hypertension prevalence and gender distribution to the national survey [
The hypertension prevalence from this study was about the same as other surveys in Iranian [
The study showed that the random blood glucose was ≥ 6.1 mmol/dL is almost the same prevalence of diabetes that was demonstrated in the national survey [
Dyslipidemia (high LDL, low HDL, and high TG) is associated with increased CVD risk (WHO, 2010). The study showed the prevalence of total cholesterol level of ≥5.2 mmol/dL to be much lower than that found in the national survey (40.6%) [
The study showed the LDL levels among the participants to be mainly in <2.6 mmol/dL (62.36%), but in 26.81% of them it was in the range of 2.6–3.3 mmol/dL. The high prevalence of lipids disorders was demonstrated in studies [
HDL was < 1.03 mmol/dL among high percentage of the participants which along with unhealthy behavior of physical inactivity and unhealthy diet, obesity, and other dyslipidemias can contribute to CVD risk. Similar findings of a low HDL prevalence of have been found in Iran [
This study found high triglycerides levels of the participants, almost the same as those found in Iran third national survey [
Only (4.65%) had 3–5 risk factors. A similar finding was found in a survey from Oman [
In conclusion, CVD risk factors have high prevalence in the Middle East region including behavioural, physical, and biochemical measurements.
Despite high prevalence of individual CVD modifiable and major risk factors, the prevalence among the participants of composite CVD risk factors was found to be low. That can encourage for the recommendation for interventions and lifestyle modifications at the population level and at work sites.
The findings of the analysis were in line with many studies conducted at the country level and in the region.
The high prevalence of CVD risk factors among participated employees reflected alarming public health concerns and a future health demand. It constitutes a threat if health promotion and awareness programs are not well designed.
Although NCD indicators are set, health policies are in place, clinical guidelines for major CVD risk factors are available, continuous surveillance for CVD risk factors are to be strengthened, and guidelines for CVD detection and prevention are needed. Moreover, future researches are recommended.
The authors declare that there is no conflict of interests regarding the publication of this paper.
First, special thanks are due to Professor David Wood (author) for his guidance and support. The authors would like to extend their thanks to Paul Bassett for providing the required statistical training. They would like to thank Dr. Mariam AL-Jalahama, assistant undersecretary of primary health care and public health, Ministry of Health in Kingdom of Bahrain, for her continuous help, support, and guidance. A special thank is due to Dr. Khairiya Moosa director of public health for her time and support. Dr. Abdulhussain AL ajmi (Author) is a special person for his endless guidance, support, motivation, and one to one advice. Thanks and love are due to my (author’s spouse) loving, caring, and supporting husband Hussain AL-sammak. In addition, the author would like to thank the campaign team, who participated in the data entry and collection.