The Burden of Cardiovascular Disease in West Virginia
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Appendix A
Appendix B
Appendix C
Appendix D

Symbol - map of WV with a human cardiovascular system imposed on it. Chapter Two
Cardiovascular Disease Risk Factors
Risk Factor Surveillance | Tobacco | Hypertension | Oral Health | Physical Inactivity | Dietary Factors | Diabetes | Multiple Risk Factors

There is no doubt that certain risk factors increase a person's chances of developing and perhaps dying from cardiovascular disease. These have been classified as either modifiable or nonmodifiable in terms of their amenability to intervention. Age, gender, race, and heredity, discussed in Chapter One, are usually thought of as nonmodifiable risk factors. Men have higher mortality rates from CVD than women throughout life (although CVD mortality is the number one killer of both men and women), CVD risk increases with age, African Americans have higher CVD mortality rates until advanced age, and a family history of CVD increases an individual's risk, either because of genetics or similar cultural patterns such as diet (3).

Modifiable risk factors are those behaviors that are considered to be under the control of the individual. The major independent modifiable risk factors for CVD that have been identified are tobacco use, physical inactivity, hypertension, and high serum cholesterol levels. Others include diabetes, obesity, and environmental tobacco smoke. Recent studies have also demonstrated the link between periodontal disease and/or tooth loss and cardiovascular disease. The table below presents the best estimates of the percentages of coronary heart disease, the most prevalent manifestation of CVD, attributable to some of the modifiable risk factors discussed in this report.

Table 2.1
Percentage of Coronary Heart Disease Attributable to Selected Risk Factors
Risk Factor
Best Estimate Range
Cholesterol 200 mg/dL or greater 43% 39%-47%
Physical Inactivity 35% 23%-46%
Blood Pressure 140/90 mm Hg or greater 25% 20%-29%
Cigarette Smoking 22% 17%-25%
Obesity* 1 7% 7%-32%
Diabetes (fasting glucose 140 mg/dL or greater) 8% 1%-15%

Source: Brownson RC, Remington PL, Davis JR, eds. Chronic Disease Epidemiology and Control. Washington, DC: American Public Health Association, 1993.
* Based on body mass index of greater than 27.8 kg/m2 for men and 27.3 kg/m2 for women.

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Risk Factor Surveillance. The Behavioral Risk Factor Surveillance System (BRFSS) is a monthly telephone survey established by the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta that allows states to monitor the prevalence of selected health behaviors among their adult residents (aged 18 and older). West Virginia's involvement with the BRFSS since its inception in 1984 (when only 15 states participated) has provided the state with a mechanism to measure the rates of cigarette smoking, smokeless tobacco use, hypertension, high cholesterol levels, tooth loss, obesity, physical inactivity, and diabetes over the years. Since 1990, when 45 states participated in the BRFSS, the national numbers have been sufficient to provide U.S. median values for risk factors with which to compare state rates. Each year since 1997, there have been 52 participating jurisdictions, i.e., the 50 states, the District of Columbia, and Puerto Rico. Appendix A contains tables presenting the 1999 (or latest year available) statewide prevalence data for each of the risk factors presented in this chapter by age, gender, educational level, and household income, as well as trend data where available for West Virginia and the United States. County prevalence data2 for selected risk factors are also included in Appendix A.

The source for the youth risk factor data presented in this chapter is the Youth Risk Behavior Surveillance System (YRBSS), a national school-based survey of 9th through 12th grade students conducted by CDC and state, territorial, and local school-based surveys administered by health and education agencies. The 1999 data are derived from the national survey and a West Virginia survey, one of 33 such state surveys. The YRBSS monitors six categories of high-risk behaviors, including the CVD risk factors discussed here. County data2 are not available for the YRBSS survey results. Youth data were also obtained from the 1998 West Virginia Oral Needs Assessment conducted by the Office of Maternal, Child and Family Health, West Virginia Bureau for Public Health.

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Tobacco Use

No other single risk factor is associated with the range and variety of negative health outcomes as tobacco use, ranging from cardiovascular disease and cancer to unsuccessful pregnancies, intrauterine growth retardation, and low birthweight to peptic ulcer disease, dental decay, and tooth loss. Whether cigarette smoking, pipe or cigar smoking, or chewing tobacco or snuff, the use of tobacco is a complex behavior, but nevertheless one that is amenable to public health intervention. Cigarette smoking and smokeless tobacco use will be addressed in this section; prevalence data on pipe and cigar smoking are too sparse to allow valid analysis.

Cigarette Smoking. In the 1990s, cigarette smoking was dubbed the "risk factor of the century" (3). It is has been calculated that some 20% of deaths in the United States annually are related to cigarette smoking in some way; approximately 4,200 deaths in West Virginia each year are considered smoking attributable (15). While the effects of smoking on the respiratory system are widely recognized and certainly place a huge burden on the public health system, the costs to society due to tobacco's contributions to vascular diseases are even greater. It is well established that nicotine's effects on blood vessel walls make them more receptive to the buildup of plaque, leading to atherosclerosis, while concurrently decreasing the oxygen-carrying capacity of the blood (16). Exposure to cigarette smoke, whether through actual smoking or passively through contact with environmental tobacco smoke (ETS), can increase cholesterol and triglyceride levels, increase blood pressure, and cause cardiac arrhythmias. While smoking is detrimental to everyone, there is recent evidence to suggest that there are even worse consequences for female smokers. The results of a Danish study published in the British Medical Journal showed that women are 50% more likely than men to have a heart attack as a result of smoking (17).

When smoking is combined with other risk factors such as high cholesterol levels and hypertension, a synergistic effect results that greatly increases an individual's risk of cardiovascular disease. A report published in 1992 detailing results from the Multiple Risk Factor Intervention Trial (MRFIT) initiated in the mid-1970s confirmed these effects (3). The trial included risk factor screening of 342,815 men who were free of known heart disease or diabetes and subsequently followed for an average of 11.6 years to ascertain the occurrence of deaths due to coronary heart disease. The cohort was divided into quintiles according to levels of hypertension and serum cholesterol concentration and further divided into smokers and nonsmokers. Results showed that smokers in the top quintiles of both high blood pressure and high cholesterol were at the highest risk of death from coronary heart disease, a risk 20 times that of nonsmokers in the lowest quintiles of the other risk factors.

Adult Cigarette Smoking. The rate of current smoking among West Virginia adults has been monitored through the BRFSS since 1984. Following a high prevalence of 33.9% reported in the first year of the survey administration, the rate of smoking in the state has remained relatively consistent, ranging between 29.6% and 24.8% (Fig. 2.1). The 1999 prevalence was 27.1%, 6th highest among the 52 BRFSS participants. The U.S. median rate for 1999 was 22.6%.

Overall, West Virginia men are still significantly more likely to smoke than women (30.2% vs. 24.4%); both sexes, however, are significantly more likely to smoke than their U.S. counterparts. While men are more likely than women to have begun smoking, women are less likely to quit once the habit has started. In 1999, 58% of women who had ever smoked were still smoking, compared to 50% of men graph showing adult cigarette smoking by year.who ever smoked. West Virginians reported higher prevalences of smoking than the U. S. average at all ages except 65 and older and at all educational levels. Smoking prevalences in 21 counties were significantly higher than the U.S. median; no counties showed a significantly lower rate (Fig. 2.2).


Figure 2.2 Pop-up map of Prevalence of Current Smoking by county.

Youth Cigarette Smoking. The national Youth Risk Behavior Survey reported a prevalence of current smoking3 among high-school-aged youth (grades 9-12) of 34.8% in 1999. Similar rates of smoking were reported by male (34.7%) and female (34.9%) students. In West Virginia, 42.2% of students reported current smoking, 43.7% of males and 40.6% of females. When asked about frequency of cigarette use, state students ranked first among participating states in percentage of both male and female students who reported frequent cigarette use. Among males, 10.6% reported smoking more than 10 cigarettes per day, compared to 11.5% of females.

Smokeless Tobacco. Smokeless tobacco, i.e., chewing tobacco or snuff, is thought by many users to be a safe, or safer, alternative to cigarettes, but the facts do not support this. Smokeless tobacco actually delivers more nicotine more quickly into the bloodstream of the user than cigarette smoking. Because of its high nicotine levels, smokeless tobacco is extremely addictive and can lead to smoking. Smokeless tobacco use can result in high blood pressure, high cholesterol levels, and arrhythmia. In addition, smokeless use is associated with dental decay, gum disease, and tooth loss, independent risk factors for cardiovascular disease (18).

Adult Smokeless Tobacco Use.
West Virginia has traditionally had a serious problem with smokeless tobacco use among its adult male residents. The overall 1999 BRFSS prevalence for smokeless tobacco use of 8.6% actually represents a use rate of 17.5% among males, compared to
only 0.6% among females. The state has included questions concerning smokeless tobacco use in the BRFSS survey since 1986; while a varying number of BRFSS participants have included the topic in their surveys since that year, West Virginia has consistently ranked first or second among them in smokeless tobacco use. Smokeless tobacco use peaks among men aged 18-34 and those with a high school education or less.

Youth Smokeless Tobacco Use. West Virginia's problem with smokeless tobacco use is even more pronounced among its male high school students. In 1999, 28.6% of the state's male students in grades 9-12 self-reported using smokeless tobacco on the Youth Risk Behavior Survey, the third highest rate among the participating states. The overall prevalence among male students in the U.S. was 14.2%

Current Overall Tobacco Use. When those individuals who smoke cigarettes and/or use smokeless tobacco products are combined, the true magnitude of the problem posed by overall tobacco use is apparent. One in three (33.4%) adult West Virginians reported using some form of tobacco in 1999, 43.0% of men and 24.7% of women (Fig. 2.3). Even more disturbing, one-half (49.4%) of all high school students surveyed in the 1999 YRBSS reported having smoked cigarettes or cigars or used chewing tobacco or snuff on at least one day during the month prior to their interview, 53.4% of males and 44.9% of females.

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Hypertension Awareness

"The death rate of a population is determined in part by its blood pressure distribution," writes Darwin Labarthe in The Epidemiology and Prevention of Cardiovascular Diseases: A Global Challenge (3). Hypertension, or high blood pressure, has long been recognized as an independent risk factor for cardiovascular disease. While a major risk factor for coronary heart disease, it is the most important risk factor for stroke.

The term blood pressure refers to the amount of force exerted by the blood against the walls of the arteries, which is expressed as two numbers such as 120/80 mm Hg. The top number represents the systolic pressure, or the amount of force exerted when the heart beats. The bottom number represents the diastolic pressure, or the force exerted when the heart is at rest. While an individual's blood pressure fluctuates during the day, hypertension exists when the pressure is consistently above normal readings for a period of time. Normal blood pressure is defined as a persistent reading below the level of 130 mm Hg for systolic pressure and 85 mm Hg for diastolic pressure. High normal blood pressure includes readings of 130-139 mm Hg for systolic and 85-89 mm Hg for diastolic pressure. Hypertension refers to consistent readings of equal to or higher than 140 mm Hg for systolic pressure and 90 mm Hg for diastolic pressure. Persons with a family history of high blood pressure are at increased risk for hypertension. In addition, Diet and Health: Implications for Reducing Chronic Disease Risk concluded that "obesity and alcohol intake are related to increased risk of high blood pressure and that dietary sodium is a major factor but requires individual susceptibility for its effect" (19).

The West Virginia Bureau for Public Health has tracked the prevalence of hypertension awareness (a "yes" answer to the question "Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?") among state adults since 1984. From 1984 through 1997, the overall prevalence in the state fluctuated between 24% and 29%, averaging an annual increase of 0.1%. The state's 1999 rate rose to 31.0%, significantly higher than the national rate of 23.9% and the second highest among the 52 BRFSS participants in that year. (Hypertension awareness questions have only been asked in odd-numbered years since 1997.)

Both men and women in West Virginia reported significantly higher rates of hypertension awareness in 1999 than respondents in the rest of the country. In both the state and the nation, hypertension awareness increases with age and decreases with higher levels of education; however, significantly higher rates were noted in West Virginia among all age groups except 65 and older (Fig. 2.5) and at all educational levels. Twenty-three of the state's 55 counties reported significantly higher rates of hypertension, with only five counties having rates lower than the U.S. rate and only one, Monongalia County, reporting a significantly lower rate (Fig. 2.6).

Figure 2.6 Popup map of Prevalence of Hypertension Awareness by county.

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Oral Health

Under the leadership of Dr. David Satcher, the first Oral Health in America: A Report of the Surgeon General was published in 2000. The intent of the report was to inform Americans of the importance of oral health to their overall health and well-being. It is increasingly recognized that an individual's oral health has a tremendous effect on his or her general health; as the report states, "you cannot be healthy without oral health (20)."

Some decades ago, the Finnish government undertook a study to determine the major health risks among the Finnish people. The results were published in an article by Mattila et al. in the British Medical Journal in 1989. An unexpected association was discovered between dental disease and systemic disease (i.e., heart disease, stroke, and diabetes) even after controlling for age, physical activity, weight, smoking, diet, cholesterol levels, alcohol use, and health care. There have been numerous studies since then confirming the correlation between oral health and cardiovascular health. Loesche et al. reported in the Journal of the American Dental Association in 1998 that a statistically significant association existed between a diagnosis of coronary heart disease and certain oral health parameters, including number of missing teeth, all of which were independent of and more strongly associated with coronary heart disease than cholesterol levels, weight, diabetes, and smoking status (18). An earlier study (1997) showed missing teeth to be a more likely indicator of ischemic heart disease than smoking. Reporting their results in the Journal of Cardiovascular Risk in 1999, Morrison et al. found a two-fold higher risk of dying from cardiovascular disease among persons with periodontal disease; smokers, on the other hand, had only a 1.6-fold higher risk (21).

Adult Oral Health. The BRFSS offered an optional oral health module with its core questionnaire from 1995 through 1997. During that time, 46 states administered the module at least one year. One of the questions asked concerned edentulism, or loss of all natural teeth. One of the national 2010 health objectives is to reduce the proportion of older (65-74) adults who have had all their natural teeth extracted from the 1997 baseline of 26%. Overall, the BRFSS data indicated that 22.9% of all respondents aged 65-74 had lost all of their natural teeth. Of the 46 states participating in the module, West Virginia ranked first in the proportion of older adults aged 65-74 with no natural teeth at 44.2%, virtually twice the national median. Of all respondents in the state older than 65, nearly one-half reported having no natural teeth (47.9%).

In 1999, the BRFSS core questionnaire addressed some aspects of dental health, including a question on tooth loss. West Virginia respondents were significantly more likely than respondents nationwide to report that they had lost six or more permanent teeth to decay or gum disease. The state's prevalence of 35.6% was the highest of all the BRFSS participants in that year, far exceeding the national average of 19.9%. State residents were more likely than their counterparts nationwide to report such tooth loss regardless of sex and age and at all educational and income levels.

Youth Oral Health. In 1998, the West Virginia Bureau for Public Health conducted the West Virginia Oral Needs Assessment, an oral health survey of 3,635 school children aged 8 through 18 in grades 3, 6, 9, and 12 located in 10 of the state's counties (22). The survey consisted of a questionnaire to be filled out by students and their parents and an oral health exam conducted by licensed dentists using CDC oral health survey protocol. While overall dental habits and knowledge of oral health needs among the state's children were deemed satisfactory, the level of dental caries in both primary and permanent teeth and the proportion of children who had received protective sealants on their permanent molars were not.

The oral health exam found that 62.2% of children examined had decay (either treated or untreated) in both dentitions, while 46.5% had decay in permanent teeth. One-third (32.9%) of the children were found to have untreated decay in both dentitions, with over one in five (22.5%) having untreated decay in permanent teeth. The percentage of children with untreated decay in permanent teeth ranged from a low of 14.0% among 8 year olds to a high of 39.8%among 16 year olds. Only 35.5% had one or more molars with permanent teeth sealants, although it was determined that 53.0% were in need of such sealants.

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Physical Inactivity

As with many of the other risk factors discussed in this report, the importance of physical inactivity in the development of cardiovascular disease, while recognized, is only now being examined in depth. Ongoing research will further determine the frequency, intensity, and types of physical activity that best contribute to the prevention of CVD, as well as to the benefits conferred for persons with existing CVD, often during cardiac rehabilitation. The mechanisms by which physical activity affects cardiac and vascular changes as well as metabolic changes are not yet sufficiently understood. In addition, demographic and psychosocial factors influencing the adoption of a more physically active lifestyle need further research to develop programs that reach everyone.

Physical activity as used in this report is defined as "bodily movement produced by skeletal muscles that requires energy expenditure"(3). Physical inactivity, on the other hand, is defined as "a level of activity less than that needed to maintain good health" (3). The biological mechanisms by which regular physical activity contributes to the prevention of CVD include strengthening the cardiac muscle, increasing the supply of oxygen to the heart, increasing heart function, and increasing the electrical stability of the heart (3). In addition, physical activity impacts many of the other recognized CVD risk factors, being associated with reduced risks of obesity, hypertension, high cholesterol levels, and Type 2 diabetes. In contrast to regular physical activity, inactivity causes a deterioration of the body. Without adequate activity, the cardiovascular system will degenerate, which in turn will lead to the breakdown of the body's other systems. This degeneration, however, might not become evident until many years of abuse have occurred.

Adult Physical Inactivity. Physical activity, or lack of, is monitored by the BRFSS every other year, with 1998 being the most recent data available for the present analysis. Since 1990, West Virginians have consistently reported significantly higher rates of physical inactivity than respondents in the U.S. as a whole (Fig 2.8). In 1998, 43.7% of BRFSS respondents reported no leisure-time activity during the month prior to their interview, compared to a U.S. median prevalence of 27.7%, placing the state third highest among the 52 participants.

State men (43.0%) and women (44.4%) reported similar rates of physical inactivity in 1998, and respondents in all age groups reported significantly higher rates than the average for their U.S. counterparts. The same was true for West Virginians in all educational and income levels. Forty-three (43) of the state's 55 counties reported rates of physical inactivity that were significantly higher than the 1996 U.S. median of 29.7%, with only Ohio County reporting a significantly lower rate (Fig. 2.9).

Popup map of Prevalence of Physical Inactivity by county.

Youth Physical Inactivity. The 1999 Youth Risk Behavior Survey included several questions concerning physical activity. Similar percentages of state and national high school students reported having participated in vigorous physical activity4 (64.7% vs. 62.4%, respectively) and strengthening exercises5 (53.6% vs. 55.8%, respectively). A marked difference was noted, however, in enrollment in physical education classes; 56.1% of students nationwide reported being enrolled in a physical education class at the time of their interview, compared to only 38.2% of West Virginia students. Interestingly, of those students enrolled in physical education classes, more state students reported that they exercised at least 20 minutes during an average class than students nationwide (84.6% vs. 76.3%). On the other hand, fewer state students reported playing on a sports team than their national counterparts (49.5% vs. 55.1%).

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Dietary Factors

Among the recommendations for primary prevention of cardiovascular disease are to maintain a healthy weight, increase the amount of dietary fiber from grains, fruits, and vegetables included in the daily diet, and decrease the intake of fat, saturated fat, and cholesterol. These recommendations are incorporated into the most recent version of the food guide pyramid issued by the U.S. Department of Agriculture (USDA): carbohydrates in the broad base, fruits and vegetables in the second tier, dairy products, animal protein, beans, and nuts in the third tier, and fats, oils, and sweets in the peak of the pyramid (3). Evidence shows that following these guidelines will, when coupled with adequate physical activity, result in an appropriate weight for height and lower damaging cholesterol levels in the blood.

Consumption of Fruits and Vegetables. Fruits and vegetables provide a major source of complex carbohydrates and dietary fiber, as well as adding vitamins and minerals to an individual's diet. The Health Professionals Follow-up Study collected detailed dietary information from a cohort of 43,757 men aged 40-75 years, who were then followed for six years to ascertain the occurrence of coronary events (23). The results, which were published in the Journal of the American Medical Association in 1996, pointed to a direct association between increased dietary fiber intake and a lower incidence of coronary heart disease. The study estimated that every 10-gram increase in fiber intake per day results in an average reduction of approximately 19% in the risk of coronary death.

Adult Consumption. Questions on the consumption of fruits and vegetables are included in the BRFSS survey in even-numbered years. The USDA recommends a minimum of five servings of fruits and vegetables daily. Data collected in 1998 indicated that, overall, fewer than one in five adult West Virginians (18.7%) are consuming that amount each day (Fig. 2.10), compared to a national average of 23.8%. Women are more likely to eat five or more servings of fruits and vegetables than are men (21.9% vs. 15.0%). Nearly one-half (45.3%) of men and one-third (34.0%) of women, however, reported that they ate two or fewer servings per day. Adults aged 65 and older reported including at least five servings of fruits and vegetables in their daily diets slightly more frequently than younger respondents (22.3% vs. 17.7%). Respondents with more education and higher incomes were more likely than others to report following USDA recommendations; nevertheless, not one demographic group studied reached the target prevalence of 35% set in West Virginia Healthy People 2010 Objective 19.2 (24).

Youth Consumption. Slightly more youth in West Virginia are eating the USDA recommended five or more servings of fruits and vegetables than the adult population: 20.4% of high school students responding to the Youth Risk Behavior Survey reported this behavior, including 19.4% of females and 21.5% of males. State youth are less likely to meet USDA recommendations than their counterparts nationwide, however. Twenty-four percent (23.9%) of respondents to the national YRBS reported that they had eaten five or more servings of fruits and vegetables daily during the seven days prior to the interview, 23.4% of females and 24.4% of males.

Obesity. Obesity continues to be of mounting concern to public health professionals, both in West Virginia and in the country as a whole. While there has been general consensus with the National Institutes of Health's definition of obesity as "an excess of body fat frequently resulting in a significant impairment of health," there has been less agreement over the years on the best way to measure obesity. In past years, obesity was represented as having a body weight greater than 120% of "ideal weight" using the Metropolitan Life Insurance Company's 1959 Height and Weight Tables as the standard. Recently, "body mass index," a ratio of weight to height (kg/m2), has become more commonly used to determine obesity and has been adopted by the West Virginia BRFSS.

Whatever measurement or definition is used, there is no argument that obesity is a significant problem in terms of cardiovascular health. In fact, in 1998 the American Heart Association reclassified obesity as a major, modifiable risk factor for coronary heart disease and issued a "call to action" to the medical and research communities, as well as to the general public. Results from the 26-year follow-up analysis of the Framingham Heart Study indicate that relative weight (as measured in terms of "ideal weight") is independently associated with coronary events, coronary death, and congestive heart failure in men and with fatal and nonfatal heart disease, stroke, and congestive heart disease in women (25). Obesity also contributes to cardiovascular disease indirectly by increasing the risk for hypertension, diabetes, and higher total serum cholesterol and LDL levels and lower HDL levels. When excess weight accumulates around the waist, women become particularly prone to cardiac problems.

Obesity among Adults. The measurement of obesity employed in the 1999 BRFSS is body mass index (BMI): all respondents who have a BMI of 30.0 or greater are defined as obese. Obesity has long been a problem in West Virginia; the state prevalence has been significantly higher than the U.S. median rate every year since 1990 (Fig. 2.11). In 1999, the state rate of 24.6% was 25% higher than the national rate of 19.7%. West Virginians of both sexes and of all ages are significantly more likely to be obese than their national counterparts.

Overweight among Youth. Students who were interviewed in the 1999 Youth Risk Behavior Survey were defined as "overweight" if they were in the 95th percentile or greater for body mass index by age and sex.6 Nationally, 9.9% of all students were overweight, 7.9% of females and 11.9% of males. In West Virginia, 12.2% of all students were overweight, 8.3% of females and 15.8% of males (Fig. 2.12). An additional 16.0% of youth in both the U.S. and West Virginia were at risk for becoming overweight7 (14.4% of females and 17.5% of males nationally and 15.4% of females and 16.5% of males statewide).

chart showing increase in adult obesity from 1987 to 1999>  </p>
      <p align=graph showing youth at risk for overweight and overweight. 

High Cholesterol. High levels of cholesterol in the blood have been well recognized as a risk factor for cardiovascular disease, in particular coronary heart disease. Many studies, including the Framingham Heart Study, have demonstrated that an increased level of blood cholesterol results in an increased risk of coronary heart disease (16). According to guidelines set by the National Institutes of Health, a total serum cholesterol level of less than 200 mg/dL is considered desirable, while a level of 200-239 is borderline, and a level of 240 mg/dL or greater is high (16). The American Heart Association estimates that roughly one out of every two American adults has a higher than desirable cholesterol level, diagnosed or not (2).

Cholesterol is divided into four major classes: low-density lipoprotein (LDL); very-low-density lipoprotein (VLDL); intermediate-density lipoprotein (IDL); and high-density lipoprotein (HDL). While total serum cholesterol has long been considered an indicator of risk for CHD, it is now generally accepted that the LDL component of cholesterol plays the most important role in the development of atherosclerosis, i.e., the accumulation of cholesterol on the inner walls of the arteries. As the lesions, or plaques, that form due to the extra cholesterol become larger, narrowing of the arteries results, allowing less blood flow to the heart and increasing the risk of heart disease. High levels of HDL cholesterol, on the other hand, are actually associated with a lower risk of coronary heart disease (16). The National Heat, Lung and Blood Institute issued new guidelines for HDL and LDL levels in 2001 raising the minimum desirable reading for HDL to 40 mg/dl and the optimal high level of LDL to 100 mg/dl (26). Total cholesterol level is a stronger indicator of heart disease for men than women; the level of HDL is a more reliable indicator of potential disease for women (14).

High blood cholesterol can be reduced by decreasing consumption of saturated fats, which are those that come from animal sources and those that remain solid at room temperature, including some vegetable shortening and margarine. Better choices for a healthy diet are polyunsaturated fats, such as those found in safflower and soybean oils, and monounsaturated fats, found in olive and canola oils. The use of unsaturated fatty acids has been shown to lower LDL cholesterol without reducing HDL. The consumption of soluble fiber as is found in whole grains has also been demonstrated to reduce cholesterol levels. These diet recommendations apply to both adults and children over the age of two.

Questions on cholesterol screening were included in the BRFSS survey from 1987 through 1993 and in odd-numbered years since. The 1999 BRFSS results showed adults in West Virginia to have a serious problem with high cholesterol. In that year, West Virginian respondents were significantly more likely than the national average to answer "yes" when asked "Have you ever been told by a doctor or other health professional that your blood cholesterol is high?" In fact, West Virginia reported the highest prevalence of cholesterol awareness among all 50 states, the District of Columbia, and Puerto Rico. Thirty-seven percent (37.1%) of state adults had been diagnosed with high cholesterol, compared to 30.0% of adults in the United States as a whole, a rate 24% higher than the national one. Nearly four in every 10 (39.1%) women in the state reported a diagnosis of high cholesterol, while 34.7% of men did so. West Virginians in all age groups over 25 (Fig. 2.13), all household income levels, and all educational levels reported higher rates of having received a diagnosis of high cholesterol than respondents nationwide.

Graph of percentage of adults diagnosed with high cholesterol by age grouping.

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"Diabetes" is actually a general term for a number of metabolic disorders that are characterized by hyperglycemia, i.e., the inability of the body to produce or respond normally to insulin, a hormone produced by the pancreas (27). Without insulin, the body cannot properly convert food into energy. The most frequently diagnosed types of diabetes are Type 1 and Type 2 diabetes. Type 1 diabetes, or immune-mediated diabetes, results from the autoimmune destruction of the Beta cells in the pancreas and subsequent total lack of insulin secretion. It is usually diagnosed before the age of 30 and requires daily insulin supplementation and meal and exercise planning. Approximately 5%-10% of the population having diabetes has Type 1. Type 2 diabetes, by far the most common, is caused by a combination of insulin action resistance and an inadequate compensatory insulin secretory response. Those diagnosed with Type 2 diabetes are often obese with a family history of the disease. Treatment for Type 2 diabetes ranges from control through careful eating habits and regular exercise to oral hypoglycemic agents to insulin injections. While Type 2 diabetes usually appears after the age of 40, there recently has been an increase in its diagnosis among younger persons. Between 1990 and 1998, diabetes increased 33% nationwide, but rose 70% among persons aged 30 to 39 (28). There is no cure for either type of diabetes; it is a chronic disease that requires lifelong care.

There is an increased risk for cardiovascular disease inherent in diabetes. Diabetes increases the risk of coronary heart disease by two to three times (29) and perhaps even more for women; it is estimated that diabetes contributes to as many as one in every five post-menopausal heart attacks (14). The risk of stroke has been calculated at anywhere from two to six times higher for persons with diabetes, also higher for women than for men (16). CVD constitutes the leading cause of death among persons with diabetes. In the diabetic patient, atherosclerosis occurs at an earlier age and with greater frequency than in the general population (3). Heart disease in the diabetic population is often "silent," i.e., manifested by dyspnea (shortness of breath) rather than by angina; the presence of diabetes is the number one predictor of heart failure and restenosis after angioplasty.

Every 60 seconds at least one person in the United States is diagnosed with diabetes (28). Approximately 800,000 new cases of diabetes are diagnosed each year (28). To date, it is estimated that 16 million people in the United States have diabetes; however, only 10 million have been diagnosed (30). Undiagnosed diabetes is of great concern because of the serious complications that can occur if the disease is left untreated.

In 1999, the prevalence of diabetes among adults in West Virginia was 7.3%, compared to 5.6% in the nation as a whole, a statistically significant difference. West Virginia's rate was the fourth highest among the 52 BRFSS participants in that year. Both men and women in West Virginia reported higher rates of diabetes, although only the difference between state and national women was statistically significant. Diabetes prevalence increases with age; 15.5% of state adults aged 65 and older reported having diabetes. Higher rates were also reported by persons with less than a high school education and those with household incomes of less than $15,000.

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Multiple Risk Factors

Health care professionals are well aware that most patients have multiple cardiovascular risk factors, adding to the complexity of prevention and treatment of the disease. Data from the 1996 BRFSS were the latest available to examine the interrelationships among four of the CVD risk factors monitored by that system8. Table 2.2 presents an examination of respondents in that year who reported current smoking, physical inactivity, hypertension, and/or obesity. Seven out of every 10 (70.5%) respondents reported being at increased risk of developing cardiovascular disease from at least one of these four risk factors. One-fourth (25.4%) reported having two CVD risk factors, while 8.8% reported three.

Table 2.2. Respondents at Risk for CVD due to Obesity,
Current Smoking, Hypertension, and/or Physical Inactivity by Percentage
1996 West Virginia Behavioral Risk Factor Surveillance System
Risk Factor(s) Contributing to CVD % at Risk
None 29.5
One Risk Factor 35.5
   Obesity (BMI 30 or greater) 4.4
   Current Smoking 8.8
   Hypertension 8.3
   Physical Inactivity 14.1
Two Risk Factors 25.4
   Obesity and Current Smoking 1.3
   Obesity and Hypertension 2.7
   Obesity and Physical Inactivity 3.9
   Current Smoking and Hypertension 1.6
   Current Smoking and Physical Inactivity 9.5
   Hypertension and Physical Inactivity 6.5
Three Risk Factors 8.8
   Obesity, Current Smoking, and Hypertension 0.8
   Obesity, Current Smoking, and Physical Inactivity 1.5
   Obesity, Hypertension, and Physical Inactivity 4.1
   Current Smoking, Hypertension, and Physical Inactivity 2.4
Four Risk Factors 0.8
   Obesity, Current Smoking, Hypertension, and Physical Inactivity 0.8

A combination of risk factors can have a synergistic effect on the chances of developing cardiovascular disease, as well as the severity of the disease, and the effective treatment of cardiovascular disease recognizes this fact. Any effort to address unhealthy behaviors must involve the determination of realistic goals in motivating lifestyle changes. The unwillingness of a patient to change one unhealthy behavior does not necessarily extend to other behaviors under his or her control. Even the elimination of one risk factor can make a difference in the likelihood of an individual's developing cardiovascular disease.

The BRFSS subpopulations of smokers, hypertensive persons, obese persons, and persons reporting a physically inactive lifestyle were further examined in terms of those respondents who reported two or more risk factors. These breakdowns are presented in Figures 2.15 through 2.18.

Current Smoking. Smokers represented 26.6% of all respondents to the BRFSS in 1996. Among smokers, 32.9% reported smoking as their only CVD risk factor, while 35.6% reported smoking plus physical inactivity. Five percent (5.0%) of smokers were also obese, while 5.9% were hypertensive. Over seventeen percent (17.6%) of current smokers reported three risk factors, and 3.0% reported all four risk factors.

Physical Inactivity. Overall, 42.7% of respondents to the 1996 BRFSS reported a physically inactive lifestyle. Of these respondents, one-third (33.0%) did not report any other CVD risk factors. Over one-fifth (22.1%) also smoked, 15.3% were hypertensive, and 9.0% were obese. Nearly one in five (18.6%) reported two additional CVD risk factors, while 1.9% reported all four. Figure 2.16 illustrates the breakdown of physical inactivity and smoking, obesity, and hypertension.

Obesity. The prevalence of obese respondents who report other CVD risk factors is presented in Figure 2.17. Almost twenty percent (19.9%) of the 1996 BRFSS respondents were obese, using the most recent CDC definition of obesity as having a BMI of 30 or greater. Among these individuals, 22.6% did not have any other CVD risk factors. Nearly one in five (19.9%) were also physically inactive, and 13.8% were also hypertensive. Over one-fifth (21.2%) reported hypertension and physical inactivity in addition to obesity. Four percent (4.1%) of obese respondents also were hypertensive, smoked, and were physically inactive.

Hypertension. Over one-fourth (27.4%) of respondents to the 1996 BRFSS reported they had been diagnosed with hypertension. Of these, 30.4% reported no other CVD risk factors. Twenty-four percent (24.0%) of hypertensives also reported a physically inactive lifestyle, while 15.1% were both obese and physically inactive in addition to having hypertension. In all, 26.9% of hypertensives reported two other CVD risk factors; 2.9% reported all four. Figure 2.18 on the following page presents the breakdown of persons with hypertension and the other CVD risk factors.

High Cholesterol Levels and Other CVD Risk Factors. As referenced earlier in this chapter, results from the Multiple Risk Factor Intervention Trial pointed to a synergystic effect between high cholesterol levels, cigarette smoking, and hypertension in producing an even greater potential for cardiovascular disease. Looking at 1999 BRFSS data for these three risk factors, persons reporting high cholesterol reported similar rates of smoking as other respondents, but were markedly more likely to have been diagnosed with high blood pressure (Fig. 2.19). Respondents with high cholesterol were also more likely to be obese than other respondents and 58% more likely to have diabetes.

Diabetes and Other CVD Risk Factors. Persons with diabetes alone already face an increased risk of developing cardiovascular disease, as noted previously. The existence of other CVD risk factors only adds to this risk. Aggregated BRFSS data for 1995-99 were examined to determine differences in risk factor prevalence among persons with diabetes compared to persons who did not have diabetes. As shown in Figure 2.20, persons with diabetes were more likely to be hypertensive, obese, and physically inactive and have high total serum cholesterol levels than respondents who did not have diabetes. On the other hand, they were less likely to report cigarette smoking than other respondents.


2 In order to provide risk factor data on a substate level, county BRFSS data were combined into a five-year aggregate. For the 1995-99 prevalence data presented in this report, 24 counties had aggregated sample sizes large enough to yield individual prevalence calculations. Samples from the 31 counties that had sample sizes too small to stand alone were combined with samples from other less-populated, contiguous counties into 12 grouping, or multicounty regions. A single prevalence was then calculated for each grouping, which was then used as the prevalence for each county within the grouping. Return to text

3Smoked cigarettes on at least one of the 30 days preceding the survey - Return to text

4Activities that caused sweating and hard breathing for at least 20 minutes on at least three of the seven days preceding the interview. - Return to text

5For example, push-ups, or weightlifting on at least three of the seven days preceding the interview. - Return to text

6Based on reference data from the National Health and Nutrition Examination Survey I. - Return to text

7Students who were at or above the 85th percentile for body mass index by age and sex but below the 95th percentile based on reference data from the national Health and Nutrition Examinations Survey I. Return to text

8Several of the risk factors, i.e., hypertension, physical inactivity, and high cholesterol, are currently addressed on a biennial basis, hypertension and high cholesterol in odd-numbered years and physical activity in even-numbered years, making cross-tabulations impossible. Return to text

Health Statistics Center (HSC)
Office of Epidemiology and Health Promotion (OEHP)
Bureau for Public Health (BPH)
Department of Health and Human Resources (DHHR)
State of West Virginia (WV)

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