disease in women, respectively.
Working as a laborer was SY M P TO M S A N D   C P VD
strongly associated with severe disease in men. Hours spent
sitting was inversely related to moderate disease in women,
as was moving about when sitting for long periods of time
in men. Fowkes et al.15 found that walking was a risk factor
for women with venous insufficiency when age-adjusted,
but less so when multiply adjusted. They found walking to
be related to lessened risk of venous insufficiency in men.15
Both Carpentier et al. and Tuchsen et al. found that men
performing unskilled work were at risk for varicose veins.13,16
Our data indicate that standing was a strong risk factor for
venous disease in women. This is concordant with a number
of studies,11,12,16 and contrasts with some other studies.15
Weight and waist circumference were risk factors for
moderate and severe disease in women and severe disease
in men. A number of studies have found an association of
obesity with venous disease. Gourgou et al.12 found a rela-
tionship in both men and women with VV. Our finding
of increased waist circumference with severe disease was
consistent with previous reports reviewed in Reference 10.
In contrast, Coughlin et al. and Fowkes et al. both found
that obesity was not a factor in venous insufficiency
among women.14,15 Fowkes et  al. extended this finding to
men as well.15 Other studies have also found no associa-
tion between obesity and venous disease.11 However, the
Edinburgh group also found that for men and women com-
bined, persons with greater severity of varices (i.e., more
segments with reflux) had higher body mass indices than
those with fewer segments involved. Additionally, Fowkes
et  al. found that varicosities in the superficial system, but
not in the deep system, were related to body mass index
(BMI) in women.15
Current cigarette smoking was associated with severe
disease in men. Gourgou et al. found a similar relationship
with VV.12
Oophorectomy and parity were both positively asso-
ciated with moderate disease in women, and parity with
severe disease as well. Gourgou et al. and Traber et al. each
found increasing VV prevalence with increasing numbers of
births.5,12 Coughlin et al. found that multiparity was associ-
ated with varicose veins in pregnant women.14 Changes can
reportedly occur with only one pregnancy.11
Our data indicate that age and family history were the
strongest risk factors for CPVD, and neither is subject to
intervention. Other significant findings on inherent fac-
tors included associations with connective tissue laxity and
inversely with African American ethnicity. Cardiovascular
disease-related factors were associated with lower rates of
venous disease. Among volitional factors important find-
ings were a relationship of CPVD with central adiposity,
positional factors such as hours spent standing or sitting,
exercise, smoking, and selected hormonal factors in women.
In contrast with prior studies, we found no relationship with
dietary fiber intake. In women but not men we confirmed
the importance of a previous lower limb injury for DFD.
EPIDEMIOLOGY OF CHRONIC PERIPHERAL VENOUS DISEASE
The SDPS reported data for ever having any of seven
symptoms of venous disease: aching, cramping, tired legs,
swelling, heaviness, restless legs, and itching.17 Aching legs
was the most commonly reported venous symptom, with
an overall prevalence of 17.7%. Cramping was present in
14.3% of legs, tired legs in 12.8%, and swelling in 12.2%.
Heaviness and restless legs had similar prevalence at 7.5 and
7.4%. Itching was the least commonly reported symptom,
affecting 5.4 % of legs. With the exception of restless legs,
all these symptoms increased in prevalence with increas-
ing severity of venous functional disease (see Figure  3.2).
The rate was lowest in normal legs, increased in legs with
SFD, and highest in legs with DFD. These differences were
statistically significant (p < 0.01) for all symptoms except
for restless legs (p  =  0.56). Although each symptom was
more common in women than men, trends were similar in
both sexes.
Escalating rates of symptoms were also found across cat-
egories of visible venous disease.17 Figure 3.3 shows the prev-
alence rates by symptom and visible category for each sex.
Symptom prevalence in subjects with TSV, the most com-
mon category of visible disease, was only marginally greater
than in normal participants. Symptoms were generally
about twice as common when VV was present. Rates were
further increased in the presence of TCS. Again, with the
exception of restless legs (p = 0.06), these differences were
highly statistically significant (p < 0.01). Similar to func-
tional disease, symptom prevalence was uniformly greater in
women although trends were similar in both sexes.
SY M P TO M S BY VI S I B L E A N D
FUNCTIONAL DISE ASE
To estimate the relative importance of each symptom to
the clinical picture of venous disease we evaluated the odds
ratios (OR) for each symptom in each of the twelve catego-
ries of venous status formed by crossing the three catego-
ries of functional disease with the four categories of visible
disease using logistic regression adjusted for age, sex, BMI,
education, and racial/ethnic group (Table 3.4). Aching (OR
2.20) and swelling (OR 2.99) were significantly associated
with DFD even in subjects without visible disease. These
two symptoms were significantly associated with DFD
across all categories of visible disease with the strongest
association in subjects with TCS. Aching was significantly
associated with VV regardless of venous functional status
and was associated with TCS except in those with normal
functional examinations. Itching followed a similar pattern
being significantly associated with VV regardless of visible
status, and with TCS except in those with normal functional
exams. However, the OR for itching with VV and DFD was
twice the level of the parallel ratio for aching (5.31 and 2.82,
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