Cardiovascular disease risk profile among young Saudi women of Al-Qassim, Saudi Arabia: A cross-sectional study

Introduction

Cardiovascular diseases (CVDs) are the primary cause of death, worldwide; and CVD accounts for 31% of all deaths (World Health Organization (WHO)) ⁽¹⁾ More than 18 million people have CVD-related death annually. ⁽¹⁾ CVDs are a growing health concern in the middle-eastern region and the Gulf Council Countries (GCC), specifically. ^(2-4) Among the six GCC countries, CVD was estimated to account for 45% of deaths, overall. Oman and Kuwait had the highest proportion of deaths attributed to CVD (49% and 46%, respectively); Saudi Arabia, United Arab Emirates, Bahrain, and Qatar (42%, 38%, 32%, and 23%, respectively) also had a significant proportion of CVD deaths (WHO country profiles). ⁽⁵⁾ Studies in Saudi Arabia estimated that the prevalence of hypertension is around 49%; while coronary heart disease is between 5-6%. ⁽²⁾ Efforts have been made, such as the Gulf Registry of Acute Coronary Events (Gulf RACE) and Saudi Project for Assessment of Coronary Events (SPACE), to understand the burden of disease as well as the associated risk factors. ^(6,7) The continuation of these projects in conjunction with research efforts will enable the improvement of prevention and treatment of CVD.

Both international studies (e.g INTERHEART and INTERSTROKE) ^(8,9) and regional studies (e.g. Gulf RACE) ⁽²⁾ have identified a set of common risk factors for CVD, which include the following: hypertension, diabetes, dyslipidemia, obesity, smoking, physical activity, poor diet, and alcohol consumption. Studies in Saudi Arabia suggest that the presence of these risk factors, particularly hypertension, obesity, and diabetes, continue to rise each consecutive year. ^(10-12) The CVD risk profile differs between men and women; for example men are more likely to smoke but women are more likely to be obese. ^(13,14) Also, men are more likely to have dyslipidemia but women are more likely to have type 2 diabetes. ^(15,16) Some of the gender differences may be explained by variations in study design and sample selection. In fact, men and women share some characteristics; they are similar regarding physical inactivity (75% in Saudi Arabia) and dietary habits (regular intake of high calorie and high fat foods). ^(17,18)

The study rationale is based on age and gender. First, many of the CVD risk factors are associated with age. ⁽¹⁹⁾ In order to develop strategies for primary prevention, research is needed on younger adult populations. ⁽¹²⁾Second, the common CVD risk factors disease presentation at onset differ between women and men. ^{(20, 21)} For example, women are less physically active and men are more likely to smoke. Many women who die from CVD have had no prior symptoms. ⁽²²⁾ Hence, the study objective was to develop the CVD risk profile of young Saudi women in the Al-Qassim region, Saudi Arabia. Specifically, we examine which risk factors are most prevalent among young women and to what extent the risk is elevated (i.e. number of risk factors).

Methods

Results

A total of 833 young Saudi women were enrolled in the study. Fifty percent were enrolled from malls and souks, 43% from colleges, and 7% from governmental organizations. The sample was selected from the three cities in Al-Qassim region with the largest population: Buraidah (70%), Onaizah (15%), and Medhnab (15%) (Table 1). Majority of the sample (54%) were between 20-24 years old; the mean age of the sample was 26. The age distribution for the remaining participants was as follows: 25-29 (15%), 30-34 (14%), and 35-39 (17%). We did not collect any further data on demographic characteristics of the participants (refer to discussion section).

The total prevalence of hypertension was 11.8% (Figure 1). After excluding women with known hypertension, 9.2% were identified as hypertensive. Among the 45 known hypertensive women, 20.0% reported taking medication and 46.6% had their blood pressure controlled. The total prevalence of hyperlipidemia was 2.8%, which was assessed by self-reported medical history. The total prevalence of type 2 diabetes was 2.9%. After excluding women with known type 2 diabetes, 7 new cases of type 2 diabetes were identified. Among the diabetic women, 37.5% reported taking medication and 58.3% had their blood sugar controlled. More than half of the sample (54%) was either overweight (25%) or obese (29%). The majority of the women (74%) reported physical inactivity. Smoking history was assessed but smoking was not present among the sample of young women; only 4 women reported having ever tried smoking but were not current smokers.

There were significant differences in risk factors by age group (Table 2). Obesity, type 2 diabetes, hyperlipidemia, and hypertension were significantly higher in the older age groups than the youngest age group. There were no age differences for physical inactivity; inactivity was high in all women.

More than 85% of the women had 1 or more risk factors indicating that only 15% of women were risk free (Figure 2). Majority of women had either 1 (57.5%) or 2 (20.8%) risk factors; physical inactivity and obesity were the most common. But a higher risk group (6.7%) was identified as having 3 or more risk factors. The percent of women with higher CVD risk increased incrementally with each age group (Figure 3). The oldest age group (35-39) had significantly more high risk (≥ 3 factors) women than the youngest age group (20-24), 15.1% versus 3.2%.

Table 1. Demographic Characteristics (n=833)

Table 2. Prevalence of cardiovascular disease risk factors by age groups (n=833).

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Figure 1.

Prevalence Estimates of Cardiovascular Disease Risk Factors

Footnote for figure 1: ^aObesity (BMI > 30), ^b physical inactivity (less than 2 weekly exercise sessions of at least 20 minutes).

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Figure 2.

Percent by Number of Cardiovascular Disease Risk Factors.

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Figure 3.

Percent by Number of Cardiovascular Disease Risk Factors across Age Groups.

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Discussion

The main finding of this study is that the majority of young Saudi women are obese and physical inactive, which significantly elevates their risk for CVD. The other risk factors, hypertension, hyperlipidemia, and type 2 diabetes, had lower prevalence; but still they are of concern given the young age of the sample. This study has identified a high risk group among these young women, those with 3 or more risk factors, and the prevalence of this group ranges of 3% to 15%. The findings of this study have been corroborated by earlier studies that have shown that Saudi women have high prevalence of obesity, ⁽²⁸⁾ low prevalence of smoking, ⁽²⁹⁾ but overall an elevated CVD risk. ⁽³⁰⁾ Further, prevalence of obesity and self-reported physical inactivity among Saudi women has increased significantly over a period of ten years. Obesity went from 23.6% to 44.0% and physical inactivity went from 84.7% to 98.1%. ⁽³¹⁾ The large change in CVD risk among young women has been attributed to unhealthy dietary habits and sedentary lifestyle. ^(17,19,32)

The study also showed that the level of risk significantly increased incrementally by the age groups. The percent of women at high risk was higher in women over 30 years than in those between 20-24 years. The high level of risk in young women is consistent with the reports from SPACE and Gulf RACE, which indicated that the mean age of CVD incidence was approximately ten years younger in the Gulf region compared to the European countries. ^(7,33) Given the high risk level and the earlier age of CVD development, the Saudi health authorities will have to develop better strategies and earlier intervention for prevention and treatment, respectively.

Although, it was not a primary objective; the study findings showed that neither hypertensive nor diabetic patients had their disease in control. Despite taking medication, many hypertensive women had elevated blood pressure (53%) and many diabetic women had elevated RPG (40%) in our study. The percent of uncontrolled disease in Saudi adult populations has been reported previously for hypertension ⁽¹⁰⁾ and type 2 diabetes. ⁽³⁴⁾ Approximately, 20% of hypertensive patients and 20% diabetic patients are treated but uncontrolled. The lower estimates in the previous studies are likely attributed to having a large, national database; our study estimates are based on very small numbers.

The study has several identifiable strengths. The study included a large sample and used objective measurement for obesity, blood pressure, and blood glucose. Second, the study involved community participation which raised awareness and CVD knowledge in the population as well as provided physician referral to new diagnosed cases of hypertension or type 2 diabetes. Examining level of CVD risk and identifying young women at high risk for CVD is a relatively new area of research in Saudi Arabia.

Limitations

The sample was not randomly selected and therefore, the representativeness is unknown. Second, the demographic data was limited and participant refusal data was not collected because the study was part of a public health campaign. The campaign organizers’ focus was primarily on promoting CVD awareness in order to benefit the community. Also, some of the CVD factors may be subject to information and/or recall bias since the data were self-reported. Other factors may have inter-rater reliability bias since more than one person was involved in data collection; we tried to minimize this by working in groups of twos and through employing standardized training sessions as one group. Finally, this was a cross-sectional study and does not have any follow-up data.

The conclusion of the study is that CVD risk is high at young ages in Saudi Arabia, particularly in women. CVD prevention campaigns and interventional research studies need to be undertaken. Specific studies or programs are needed to help women become more active (i.e. more walking), aid them in weight loss or weight maintenance, and identify CVD cases in the earliest possible stage.

Conflict of Interest

The authors have no competing interests to declare.

Author Contributions

All authors were involved in the design of the study, data collection and analysis plan. HK, AM and TS assisted with the data collection plan and supervised field data collection. ARM, MO and WL conducted the data analysis and drafted the initial manuscript. All authors reviewed, edited and approved the final the manuscript.