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Prevalence of Coronary Heart Disease Risk Factors in College Students

Article  in  Journal of Exercise Physiology Online · November 2016

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Journal of Exercise Physiologyonline
October 2016
Volume 19 Number 5
JEPonline
Prevalence of Coronary Heart Disease Risk
Factors in College Students
Juliana O. Torres1, Cláudia E. P. Oliveira2,3, Dihogo G. Matos4,
Pedro H. G. Gomides1, Renata A. R. Oliveira3, Felipe J. Aidar5,
Maria A. Rodríguez-Gázquez6, Osvaldo C. Moreira1,2
1
Institute of Biological Science and Health - Federal University of
Viçosa, Florestal, Brazil, 2Institute of Biomedicine - University of
Leon, León, Spain, 3Department of Physical Education - Federal
University of Viçosa, Viçosa, Brazil, 4Department of Sport Sciences,
Exercise and Health - University of Trás-os-Montes and Alto Douro,
Vila Real, Portugal, 5Department of Physical Education - Federal
University of Sergipe, São Cristóvão, Brazil, 6Nurse Faculty -
University of Antioquia, Medellín, Colombia
ABSTRACT
Torres JO, Oliveira CEP, Matos DG, Gomides PHG, Oliveira
RAR, Aidar FJ, Rodríguez-Gázquez MA, Moreira OC.
Prevalence of Coronary Heart Disease Risk Factors in College
Students. JEPonline 2016;19(5):147-158. The purpose of this
study was to establish the prevalence of coronary risk in
college students, and compared risk between genders and
years of study. Subjects consisted of 369 students who were
evaluated using the RISKO questionnaire, which assesses
eight risk factors: age, heredity, body weight, smoking, physical
inactivity, hypercholesterolemia, hypertension, and sex.
Students had a mean coronary risk score of 17.79 ± 4.53
points, which rated "below-average risk". Men had significantly
greater risk compared to the women. No difference was found
between the years of study. The prevalence of risk factors
consisted of sedentary lifestyle (59.30%), heredity (49.06%),
overweight (37.74%), hypercholesterolemia (9.97%), smoking
(5.12%), and hypertension (4.31%). It was concluded that the
coronary risk of college students was rated “below-average”,
being higher among men than women, and no difference in risk
between years of study. The most prevalent risk factors were
sedentarism, heredity, overweight, and hypercholesterolemia.
Key Words: Health, Epidemiology, Cardiovascular Disease
 148

INTRODUCTION

Chronic non-communicable diseases (NCDs) are a major public health concern, representing
a substantial portion of the expenses of the Health System and the Supplementary Health
System in Brazil (15). Estimates from the World Health Organization show that NCDs
accounted for 63% of the 36 million deaths worldwide in 2008 (30). In Brazil, NCDs are also
important, accounting for 31.3% of the deaths from cardiovascular disease and 72% of total
deaths (26). Historic mortality statistics available for Brazil and the São Paulo metropolitan
region indicate that the proportion of deaths due to NCDs has decreased, but they still have a
very high incidence and remain the leading of death in adults (13).

Cardiovascular diseases (CVDs) are the NCD that stands out among all chronic degenerative
diseases. The CVDs includes coronary atherosclerosis, strokes, and hypertension and its
complications, and is the largest cause of death in adults (2). Among the risk factors for
CVDs are overweight, obesity, physical inactivity, hypertension, smoking, diabetes mellitus,
and dyslipidemia. The prevalence the risk factors depends on genetic and environmental
characteristics, and is influenced by lifestyle habits such as diet and the level of habitual
physical activity (19,25).

While the epidemiological studies with college students found low prevalence of CVD risk
factors, the data did show the need to turn our attention to this population, considering that
individuals with high risk can develop CVD early in life (10,16,17,24). Students are subject to
special conditions to enter the university system. The academic environment can cause
changes in their lifestyles with positive and negative implications (24). They are at a critical
stage of the life cycle for the adoption of lifestyles that are practiced in the family, social, and
work environment that characterized little time to eat, often skipping meals, high intake of fast
food, decrease in physical activity, and an increase in the prevalence of consumption of
tobacco and alcohol (1,24). This unhealthy lifestyle contributes to the development of the risk
factors for CVD in college students.

Studies are needed in this population to provide consistent data on the risk factors for CVD to
better understand the genesis of CVDs to avoid the consequences. Additionally, primary
health care should be the first target for prevention efforts from health professionals to
prevent and reduce CVDs. Moreover, determining the prevalence of risk factors in a given
population stratum, such as college students, is important as a means to measure primary
risk, a fact that could potentially contribute to the reduction of cardiovascular events in college
students in the medium and long term. Furthermore, the study data can be utilized by the
public health system and personal pension provider to gain subsidies for the establishment of
effective health promotion programs for people with same characteristics (10).

Thus, the purpose of this study was to establish the prevalence of coronary risk factors in
college students in general, and to more specifically compare the coronary risk between the
male and female students and their academic year in college.

METHODS
Subjects
We conducted an observational cross-sectional study in 2013 in a representative sample of
university students attending the Federal University of Viçosa - Campus Florestal (UFV),
 149

which is located in Florestal, in the metropolitan region of Belo Horizonte, the capital of the
state of Minas Gerais. The study was conducted in three phases: (a) Approval of the project
by the Ethics Committee for Research in Humans (reference number 187/2011/ Ethics
Committee) and the research project at the Federal University of Viçosa record; (b)
Participant recruitment, and explanation of the research, data collection procedures, and risks
associated with study participation; and (c) Individual application of questionnaires to all
selected.

The sample size was calculated according to the equation proposed by Lwanga and
Lemeshow (12). A minimum sample of 349 individuals was required, considering the total
number of students attending the university (1771 students) and a standard error of 5%, with
a confidence interval of 95%.

The subjects consisted of 369 students who were randomly selected, by lot, from all years
(1st through 4th), which corresponded to 20.84% of all university students of the campus.
The selection was made using a list in which the students were organized according to their
registration numbers on an Excel for Windows spreadsheet. A random drawing was
performed without repeating the participants. The 369 students were selected, evaluated, and
divided into subgroups of the first through the fourth year of academic study for purposes of
comparison.

As inclusion criteria, all subjects were regularly enrolled at UFV at the Florestal campus.
Each subject signed the consent form to participate. All data collection procedures met the
Guidelines and Standards Regulating Research Involving Human Subjects (Resolution
466/12 of the National Health Council), in accordance with the ethical principles expressed in
the Declaration of Helsinki.

To collect the data, we used the RISKO questionnaire proposed by the Michigan Heart
Association (MHA) (14). The form of the questionnaire followed the pattern used in other
studies in Brazil (9,10). It assessed eight risk factors: age; heredity; body weight; smoking;
physical inactivity; hypercholesterolemia; hypertension; and gender. Each risk factor has six
response options, and every response is equivalent to a score that represents the entry for
that coronary risk factor. The sum of the scores obtained from the responses to the eight risk
factors corresponds to a score that represents the coronary risk. This coronary risk score is
rated through a table formulated by MHA (14), which evaluates the individual as "Well below
average" for scores lower than 11 points; "Below average" for scores between 12 and 17
points; "Medium risk" for scores between 18 and 24 points; "Moderate risk" for scores
between 25 and 31 points; "High risk" for scores between 32 and 40 points; and "Very high
risk" for scores of more than 41 points.

The questionnaire was administered to each subject by a single evaluator. The subjects
completed the questionnaire with the least possible interference from the evaluator. All
questions were answered by self-report. Therefore, all results in weight, exercise, cholesterol,
and blood pressure were derived from self-reported data.

The following criteria for consideration of risk factors were used: age greater than or equal to
40 (17); heredity, having at least one first-degree relative with cardiovascular disease in the
family (9); body mass, being more than 3 lbs overweight according to standardized scales
 150

(10); smoking, daily, weekly, or monthly for the last 12 months (22); sedentary lifestyle, not
participating in moderate or intense recreational exertion (2); cholesterol above 200 mg·dL-1
(28); and systolic blood pressure greater than or equal to 140 mmHg (4).

Statistical Analysis

The data were analyzed using the SPSS® version 21 and Epi InfoTM, and the Kolmogorov-
Smirnov test. All data are presented as means ± standard deviations. The Student’s t test
was used to compare coronary risk between genders. We used the one-way ANOVA test
with the Tukey post hoc comparison to compare coronary risk among students of different
years of study. A significance level of P<0.05 was adopted for all comparisons. Moreover, the
chi-square (2) test was used to check for differences in the prevalence of each risk factor by
genders, and the odds ratio (OR) test with confidence interval of 95% (CI95%) was used to
check for differences in the risk classification between genders and years of study.

RESULTS

The subjects consisted of 172 males and 197 females. The mean age of the sample was
22.70 ± 5.20 yrs (range: 18 to 50 yrs), and 65% were in the 1st or 2nd year of study. The
mean age of the men and women was 23.03 ± 5.96 yrs and 22.43 ± 4.40 yrs, respectively.
There were no differences found in age between sex or year of study (Table 1).

Table 1. Mean Age of College Students Evaluated by Year of Study.

Year of Study Average Standard Deviation Minimum Maximum

1st yr (n = 84) 22.99 4.57 18 50

2nd yr (n = 119) 22.78 5.69 18 50
3rd yr (n = 94) 22.45 4.53 18 44
4th yr (n = 72) 22.61 5.86 18 50

Total (n = 369) 22.70 5.20 18 50

The average coronary risk score for all subjects was 17.79 ± 4.53 points (range: 8 to 41
points). Men scored higher (P<0.001) with a mean score of 19.38 ± 4.82 points (range 12 to
41 points). Women had a mean score of 16.41 ± 3.77 points (range 8 to 27 points). The score
obtained in the sample (men and women) fell within the category of "below-average risk".

The mean scores for coronary risk of the sample, segmented by year of study and sex, are
presented in Table 2. Subjects in the 1st, 3rd, and 4th yr of study were classified as "below
average", while subjects in the 2nd yr of study had a rating of "medium risk".
 151

Table 2. Mean Coronary Risk Scores by Years of Study and Sex.

Standard
Variable Average Deviation Minimum Maximum F P-value

Total (n = 369) 17.79 4.53 8 41

5.28* < 0.001
Gender
Female (n = 197) 16.41 3.77 8 27
Male (n = 172) 19.38 4.82 12 41
0.55† 0.67
Year of Study
1st (n = 84) 17.68 4.43 8 36
2nd (n = 119) 18.13 4.65 9 33
3rd (n = 94) 17.37 3.82 8 29
4th (n = 72) 17.93 5.30 9 41

*t of student; †F of Snedecor.

The percentage distribution of coronary risk in subjects, total and by sex is shown in Table 3.
Among men, approximately 13% of subjects were at an elevated risk for coronary disease,
while only 2.5% of women had an elevated risk.

Table 3. Distribution of Coronary Risk Category by Sex and Year of Study.

Much
Below Very
Risk Rating Below Average Moderate High OR(CI95%)
Average High
average

6.50% 45.26% 40.65% 6.50% 0.81% 0.27%

Total (n = 369)

Gender
Male (n = 172) 0.58% 39.53% 46.51% 11.05% 1.74% 0.58% 5.93 (2.20-15.96)

Female (n = 197) 11.58% 50.25% 35.53% 2.54% - - 1

Year of Study

1st (n = 84) 7.14% 47.62% 39.29% 4.76% 1.19% - 1

2nd (n = 119) 4.20% 47.06% 39.50% 8.40% 0.84% - 1.61 (0.54-4.81)

3rd (n = 94) 8.51% 41.49% 44.68% 5.32% - - 0.88 (0.25-3.18)

4th (n = 72) 5.56% 51.39% 34.72% 5.56% 1.39% 1.39% 1.45 (0.42-4.92)
 152

The prevalence of each coronary risk factor is presented in Table 4. The six variables that
were most prevalent in the responses to the questionnaire were sedentarism, heredity,
overweight, hypercholesterolemia, smoking and hypertension, respectively. Men had higher
prevalence rates than women for risk factors: smoking and hypertension. No differences were
found between genders for the other risk factors. Further, no statistically significant
differences were found in comparing risk factors between years of study, as is shown in
Table 5.

Table 4: Prevalence of Coronary Risk Factors by Sex.

Total Male Female 2 P value

Risk factor
(%) (%) (%)

Sedentary 59.30 56.98 62.94 1.13 0.29

Heredity 49.06 46.51 52.28 1.00 0.32
Overweight 37.74 34.30 41.62 1.79 0.18
Hypercholesterolemia 9.97 12.79 7.61 2.19 0.14
Smoking 5.12 9.30 2.30 8.11 <0.001
Hypertension 4.31 8.14 1.02 9.58 <0.001

Table 5. Prevalence of Coronary Risk Factors by Year of Study.

1st 2nd 3rd 4th 2 P value

Risk Factor*
(%) (%) (%) (%)

Sedentary 60.71 57.98 62.77 59.72 0.02 0.88

Heredity 45.24 58.82 54.26 33.33 1.12 0.29
Overweight 34.52 42.02 37.23 37.50 1.18 0.28
Hypercholesterolemia 7.14 15.97 8.51 5.56 1.72 0.19
Smoking 4.76 7.56 2.13 6.94 0.17 0.68
Hypertension 2.38 4.20 2.13 9.72 2.78 0.10

*No statistically significant differences were found in comparing risk factors by years of study.

DISCUSSION

The purpose of this study was to establish the prevalence of coronary risk factors in college
students, segmented by gender and years of study. The main results found are: (a) coronary
risk was more elevated in men than women; (b) greater prevalence of elevated risk in males;
(c) years of study does not seem to affect coronary risk; and (d) most prevalent risk factors
were sedentarism, heredity, overweight, hypercholesterolemia, smoking, and hypertension.
 153

The data from the present study indicate a "below average risk" (17.79 ± 4.53 points)
according to MHA for this sample of college students (14), with an elevation in men more
than woman (P<0,001). This finding is coupled with the fact that approximately 13% of the
men assessed had "moderate risk" or above, including individuals with "high risk" and "very
high risk", signaling an increase in risk of cardiac complications in these individuals. These
results are not unique in that others studies conducted with college students have also found
a greater risk in men, with some cases of very elevated risk (10,16,17).

The protection against coronary risk in women may be explained by many factors, including
but not limited to: (a) better vascular endothelial function; (b) increased levels of endothelial
progenitor cells that participate in the repair of vascular lesions; (c) better autonomic function;
and (d) female sex hormones. Singly and collectively, these factors delay the formation of
atherogenic plaque (29) as done a healthy lifestyle that helps to prevent the increase in risk
and, possibly, decrease the existing risk. Early intervention on modifiable risk factors in young
adults is not just prudent, but a necessity given the deleterious effects of aging its relationship
to CVDs (6,7).

In contrast with other studies (8,10), our results indicated that years of study did not have an
influence on the subjects’ coronary risk. A possible explanation for this discrepant result is the
homogeneous distribution of age between the years of study. The studies previously cited did
not control for this confounding variable. It is possible that this lack of control may have
influenced their results.

The most prevalent risk factor was sedentarism, which was present in 59.30% of the sample.
National data indicate that the prevalence of sedentarism in Brazil, including individuals who
report physical inactivity as well as those who have insufficient levels of physical activity,
ranges between 56.90% and 72.10% (15). Specifically, studies found a prevalence of 41.70%
for sedentary lifestyle in college students in the health area of Recife/PE (21); 44.44% in
physical therapy students (5); and 70.60% in Chilean college students (1). The prevalence of
sedentarism in the current study participants was higher than that of other studies. This
finding should be viewed with some concern because a sedentary lifestyle is associated with
the development of NCDs. Clearly, levels of physical activity have a dose-response effect on
various health indicators (11). In fact, the risk of CVD increases 1.5 times in individuals who
do not meet the minimum recommended regular exercise (17).

The second most prevalent risk factor was heredity, with 49.06% of the sample having at
least one first-degree family member with CVD. Similar findings were reported by other
studies in college students at Recife/PE with 66.4% prevalence (21), in college students of a
private university (17) with 56.41% prevalence, in Physical Education students (10) with
46.21% prevalence, and in Chilean college students (1) with 41,8% prevalence. It is
noteworthy that a family history of cardiovascular risk is a powerful and independent risk
factor associated with acute myocardial infarction (2), which has no modifiable characteristic.
Hence, it is necessary to adopt measures to achieve the lowest risk from other risk factors
that can be modified to help prevent coronary artery disease.

The risk factor of overweight was prevalent in 37.74% of the sample. National data show that
the frequency of adult overweight varies between 45.3% and 56.3% in Brazil (1). Specifically
for college students, some studies conducted in Brazil have found the prevalence of excess
 154

weight (overweight and obesity) to be between 18.02% and 38.10% (5,10). Despite the
prevalence of overweight in the sample being within the range found in other studies on
college students, it is necessary to consider that this is a sample of college students who are
exposed to the academic environment. This factor, with its attendant stress and special
characteristics, can cause changes in lifestyle with negative implications for the health status
of these students, due to the interaction between overweight with other risk factors (16). The
prevalence of overweight in the current study sample may be related to overeating (energy
intake) relative to energy expenditure, leading to a positive energy balance (27). This finding
is of concern because excess weight is associated with increased overall morbidity and
mortality due to coronary heart disease, stroke and other diseases (17).

Hypercholesterolemia was reported in 9.97% of the sample. Similar prevalence has been
reported by Morales et al. (16) with 10.60% prevalence in Chilean male college students and
by Ruano Nieto et al. (24) with 7.67% prevalence in Ecuadorian female college students.
However, discrepant values have been reported by Alarcón et al. (1) with 35% prevalence in
medical students, by Moreira et al. (18) with 27.47% prevalence in Brazilian college students,
and by Hazar et al. (10) with 32.41% prevalence in Physical Education students. Although the
current data are in agreement with, and even below, the cited studies, the prevalence of
hypercholesterolemia is noteworthy because it is a young population. It is known that higher
concentrations of total cholesterol are associated with increased low density lipoproteins,
which are related to the increased incidence of CVD, particularly when these atherogenic
lipoproteins are oxidized (3) and this scenario undergoes a negative influence during the
aging process (6).

The risk factor of smoking was present in 5.2% of the sample. In Brazil, the Ministry of Health
estimates that approximately 18.8% of the population consists of smokers (22.7% of the men
and 16% of the women) (15). Studies on college students suggest the prevalence rates of
smoking of 5.52% (10), 8.90% (23), 10.00% (5), 14.40% (22), and 14.65% (17). Despite the
smoking rates in the current study being below the national average, and below the values
reported in other studies of college students, this risk factor deserves attention because
smoking is a powerful CVD risk factor and acts synergistically with other coronary risk factors
to greatly increase the level of risk and the likelihood of death (31).

Finally, hypertension was reported in 4.31% of the sample. National data show that the
frequency of hypertension in adults (18 yrs of age and older) varies between 16.6% and
29.7% (15). Other researchers (10,17,18) indicate hypertension prevalence ranging between
1.38% and 11.11%. The scientific literature indicate that the prevalence of hypertension tends
to increase with advancing age, indicating that increasing age is a risk factor predisposing
individuals to the manifestation of this syndrome for both genders (18). With increasing life
expectancy in the world, there is a higher incidence of hypertension. Structural and
physiological changes associated with aging, especially the changes in vascular properties in
the aorta make individuals more prone to developing hypertension (6). Thus, to prevent the
increase in hypertension in later years, it is important that young adults engage in good
nutrition and physical activity.

In this sense, the development of strategies for the evaluation and prevention of coronary risk
should focus mainly on modifiable factors such as sedentary lifestyle, overweight, and
hypercholesterolemia because these three risk factors were the most prevalent in the college
 155

students evaluated. This strategy may lead to programs that reduce the probability of future
occurrence of cardiovascular events in these individuals, especially given their increased risk
during work or activities of daily living. Moreover, an intervention to reduce these risk factors
will also prevent the development of other risk factors and, consequently, the development of
CVD risk.

There are limitations with questionnaires as data collection instruments. However, the
questionnaires constitute a quick and low cost method of assessment strategy, and can aid in
determining the level of cardiovascular risk and physical health. Questionnaires are
particularly valuable when there is no possibility of conducting clinical consultations.

CONCLUSIONS

From the results of this study it can be concluded that the coronary risk presented by the
evaluated college students is rated as “below average”. This risk is greater in men and is not
related to the year of study. Additionally, the coronary risk factors most prevalent were
sedentary lifestyle, heredity, overweight, and hypercholesterolemia. The years of course work
did not influence the coronary risk.

Despite the small percentage of risk presented, it is interesting that we found cases of "high
risk" and "very high risk" in some of these students. This requires the attention of
professionals involved in primary health care because these individuals need immediate
intervention to prevent the occurrence of premature cardiovascular events.

ACKNOWLEDGMENTS
To the Coordenação de Aperfeiçoamento de Pessoal de Nivel Superior - CAPES for the
doctoral scholarship provided to Osvaldo Costa Moreira and to the Conselho Nacional de
Desenvolvimento Científico e Tecnológico - CNPq for doctoral scholarship provided to
Claudia Eliza Patrocínio de Oliveira.

Address for correspondence: Osvaldo C. Moreira, PhD, Institute of Biological Science and
Health, Federal University of Viçosa – Campus Florestal, Florestal, Minas Gerais, Brazil,
35690-000, Email: osvaldo.moreira@ufv.br

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