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April - June 2005 National Nutrition (NNHeS) Health Survey (NNHeS): and National Nutrition and Health Survey Atherosclerosis - Related Diseases and Risk Factors

Dans et al.

PJC Vol. 33, No. 2

Antonio L. Dans, MD, Dante D. Morales, MD, Felicidad V. Velandria, Ma. Teresa B. Abola, MD, Artemio Roxas Jr., MD, Felix Eduardo R. Punzalan, MD, Rosa Allyn G. Sy, MD, Elizabeth Paz-Pacheco, MD, Lourdes Amarillo, and Maria Vanessa Villarruz for the NNHeS: 2003 Group
NNHeS:2003 Cardiovascular & Endocrine Task Force Dante D. Morales (Chairman) Antonio L. Dans (Co-Chair) Felicidad V. Velandria Artemio Roxas Jr. Ma. Teresa B. Abola Esperanza I. Cabral Lourdes Amarillo Rosa Allyn G. Sy Mariano B. Lopez Charmaine Duante Felix Eduardo R. Punzalan Elizabeth Paz-Pacheco Rody G. Sy Maria Vanessa C. Villarruz

*OVERALL NNHeS 2003 Group Steering Committee: Dante D. Morales (Chairman) Esperanza I. Cabral Rosa Allyn G. Sy Mariano B. Lopez Romeo J. Santos Corazon VC Barba Rolando Enrique D. Domingo Technical Working Committee: Antonio L. Dans (Chairman) Lourdes Amarillo Charmaine Duante Felix Eduardo R. Punzalan Felicidad V. Velandria Maria Vanessa C. Villarruz Members: Milagros S. Bautista Lyn Almazan-Gomez Elizabeth Paz-Pacheco Julie Li-Yu Rodolfo F. Florentino Raymond L. Espinosa Sandra Tankeh Torres

Vicente Jose Y. Velez Milagros S. Bautista Oscar Cabahug Jovilia M. Abong Members of Task Forces: Dante D. Morales Antonio L. Dans Esperanza I. Cabral Ma. Teresa B. Abola Felix Eduardo R. Punzalan Artemio Roxas Jr. Giselle G. Domingo Rosa Allyn G. Sy Elizabeth Paz-Pacheco Jose P. Tirona Mariano B. Lopez Rody G. Sy Venancio Gloria Cecil Lim Eugene B. Reyes Romeo J. Santos Homobono B. Calleja Norbert Lingling D. Uy Benita Padilla Lyn Almazan-Gomez

Obet Tanchangco Leonila Dans Evelyn Salido Julie Li-Yu Raymond Rosales Paul Pasco Madeleine Sosa Lourdes Daez Oscar Cabahug Milagros Bautista Alexander Tuazon Felizardo Gatcheco Aurora Bauzon Linda Varona Benigno Agbayani Jovilia Abong Felicidad V. Velandria Charmaine Duante Eva Abile Juamina Belen M. Tangco Rodolfo Florentino Romeo J. Santos Ma.Lourdes Amarillo Corazon VC Barba Ma. Regina A. Pedro Franchesca Priscilla Cuevas Maria Vanessa C. Villarruz

Correspondence to : Dr. Antonio L. Dans ,Medical Research Unit, Philippine General Hospital, Taft Avenue, Manila, Philippines, Tel no. 5217793, 5239740 E-mail address: tdans@zpdee.net * First published in the Philippine Journal of Internal Medicine 2005; 43:103-115

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BACKGROUND

The objectives of this study are: 1) to determine the prevalence of 3 atherosclerotic diseases (angina, stroke and claudication) in the Philippines; and 2) to determine the prevalence of 5 risk factors for these diseases (dyslipidemia, diabetes, hypertension, obesity and smoking). Using a multi-staged cluster sampling methodology, this study evaluated 4753 adults aged 20 or more, from 2636 households, 79 provinces and 17 regions. The survey instruments included validated questionnaires, anthropometric measurements, and blood tests. The prevalence rates of angina, stroke and claudication in adult Filipinos were 12.5%, 1.9%, and 4.2% respectively. The prevalence rates of various risk factors were 8.5% for hypercholesterolemia (total cholesterol > 240 mg/dL), 4.6% for diabetes (based on fasting blood sugar > 125 mg/dL or a previous history of diabetes), and 17.4% for hypertension (BP > 140/90 mm Hg on 2 visits, or a previous history of hypertension), The prevalence of obesity was 3.2% in men and 6.6% in women when body mass index (BMI) was used . These rates rose to 12.1% and 54.8% percent respectively when waist-hip ratio (WHR) was used. The prevalence of current smoking was 56.3% in men, 12.1% in women, and 34.8% overall. Smoking, by far, was the most common risk factor noted. These data on atherosclerosis-related diseases and risk factors from the NNHeS provide clinicians and policy-makers a birds eye view of the Philippine situation with respect to vascular disease and its risk factors. These data may be used for policy formulation and program prioritization. In addition, the information may serve as baseline measures to evaluate the success or failure of atherosclerosis control programs in the country. A 2nd NNHeS is planned in the year 2008. atherosclerosis, coronary artery disease, cerebrovascular disease, peripheral arterial disease, diabetes mellitus, hypertension, dyslipidemia, smoking, obesity, survey

METHODS

RESULTS

CONCLUSION

KEYWORDS

Cardiovascular disease is recognized globally as a major problem affecting the world today 1,2 . While the risk factors for these diseases are well-accepted, several problems plague preventive efforts in developing countries. First, the prevalence of atherosclerotic diseases is not as well established as it is in developed nations of the world 3. This makes it difficult to justify preventive measures and monitor the effectiveness of preventive strategies. Second, the prevalence of risk factors for disease is largely unknown, so the contribution of each risk factor to the total burden of cardiovascular disease remains speculative. For these two reasons, it becomes difficult to prioritize approaches to disease prevention. The National Nutrition and Health Survey (NNHeS) was conducted in 2003 to 2004 as a collaborative effort among 14 Medical Specialty Associations, the Food and Nutrition Research Institute of the Department of Science and Technology (FNRI-DOST), and the Department of Health. The associations included the Philippine Lipid Society, Philippine Society of Hypertension, Philippine Heart Association, Philippine Diabetes Association, Philippine Pediatric Society, Philippine Society of Nephrology, Philippine Society of Endocrinology and Metabolism, Osteoporosis Society of the Philippines, Philippine

Association for the Study of Overweight and Obesity, Philippine Neurological Association, Philippine Rheumatology Association, Philippine College of Physicians, Philippine Society of Gastroenterology and Philippine Society of Asthma, Allergy and Immunology. The objective of the survey was to determine the national prevalence of 20 nutrition-related diseases and 14 risk factors. In this report we describe 3 atherosclerosis-related diseases (coronary artery disease, stroke, and peripheral arterial disease), and 5 of their risk factors (diabetes, dyslipidemia, hypertension, obesity, and smoking).

METHODS In brief, NNHeS was conducted in conjunction with the 6th National Nutrition Survey (NNS) of the Food and Nutrition Research Institute (FNRI) of the Department of Science and Technology (DOST). A stratified multistage sampling design was utilized, covering all the regions and provinces of the country, except for Batanes. Using the master sample of the Family Income and Expenditures Survey (FIES) of the National Statistics Office, sampling was performed by selecting barangays within a municipality, selecting Enumeration Areas (EAs) from these barangays, and selecting households from these

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enumeration areas. These selected households comprised the sample for the 6th NNS. For NNHeS, a nationally representative population was generated by sampling 25% of these households. All the members in the sampled households were included in the survey. Data Collection The study used a combination of anthropometric, biochemical, and clinical strategies for data collection. These strategies are described in detail below. Criteria for the various diagnoses are also defined. Angina and coronary artery disease The prevalence of angina was determined using a standardized questionnaire which was previously validated by the Philippine Heart Association Council on Coronary Artery Disease [see Appendix A]. Based on the questionnaire, a subject was diagnosed as having angina if there was a history of chest pain, heaviness or tightness, that occurs on exertion, and is relieved by rest or nitrates. The questionnaire had a sensitivity of 78% and a specificity of 91% when compared to a clinicians diagnosis 4. The prevalence of angina was adjusted for false positive and false negative results using the Marchevsky equation which is described below. To determine the prevalence of coronary artery disease (CAD) in general, subjects were also asked if they had been previously diagnosed to have the disease by either a doctor or a nurse. Stroke The prevalence of Stroke was determined using 2 sets of criteria - the stroke questionnaire validated by the Philippine Neurological Association [see Appendix B], and an elicited history of stroke diagnosed by a physician or nurse (previous diagnosis). Based on the questionnaire, a subject was diagnosed as having had a stroke if there was a history of sudden weakness, heaviness or numbness on one side or part of the body; or slurred speech, both lasting more than 24 hours. The validation for the PNA questionnaire revealed a low sensitivity and specificity (75.5% and 65.2% respectively) so the prevalence derived by previous diagnosis was deemed more useful . In determining the prevalence of stroke, no adjustments were made for false positive and false negative results. Claudication and Peripheral Arterial Disease The prevalence of peripheral arterial disease (PAD) was determined using the Edinburgh questionnaire or the ankle-brachial index (ABI). Usefulness of the Edinburgh

questionnaire in a Filipino population was determined by Dans and Abola et al 5 who used it to determine the prevalence of claudication in a limited sample [see Appendix C]. Using the questionnaire, a subject was diagnosed as having claudication if there was a history of calf pain on exertion relieved by rest. The questionnaire had a sensitivity and specificity of approximately 11.84% and 92.73% respectively for Doppler-confirmed PAD. Ankle blood pressure, on the other hand, was measured using a sphygmomanometer and a portable doppler ultrasound device. An ABI of < 0.90 or less was considered positive for PAD. This criterion had a sensitivity of 95% and a specificity of 100% for angiogram-detected PAD 6. No adjustments were made for false positive and false negative results using either of these criteria. Diabetes mellitus and Dyslipidemia Blood samples were drawn by venipuncture after an 8-10 hour fast, to determine fasting blood sugar (FBS), serum total cholesterol, high density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDL- C) and triglycerides. The criterion for diabetes was a fasting blood glucose level of more than 125 mg/dL or a history of diabetes or intake of oral hypoglycemic agents. Prevalence of various forms of dyslipidemia was also determined using cutoffs recommended by the NCEP ATP III 7. Hypertension Blood pressure was taken using a conventional mercury sphygmomanometer. Systolic and diastolic pressures were taken from both arms in the morning, before blood extraction. Hypertension was defined as a single visit systolic BP of 140 mmHg or more, OR a diastolic BP of 90 mmHg or more, OR a history of hypertension as diagnosed by a physician or nurse. This set of criteria had a sensitivity of 100% & and a specificity of 87.9% when compared to two-visit criteria, and a more detailed history. Obesity - Two criteria were used to determine the prevalence of obesity. Using the World Health Organization (WHO) criteria, body mass index (BMI) cutoff was >25 for overweight, and >30 for obese. For waist-hip ratio (WHR), the cutoff for obesity was 1.0 for men and 0.85 for women. Smoking To make sure that data were comparable to international studies, the WHO questionnaire was used to determine the prevalence of smoking. Subjects were classified as never smokers, ever-smokers or currentsmokers.

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Data Encoding, Validation and Analysis During the field data collection, all the study leaders and senior FNRI staff conducted spot checks of randomly selected subjects to ensure that data collected were complete, reliable and valid. In addition to this, clinical researchers and team leaders were required to review the accomplished questionnaires at the end of the day to check for completeness, inconsistencies and vague answers. Upon return to the office, a thorough re-checking and proper encoding were undertaken to further reduce errors in data entry. CSPro version 2.4 was used for data encoding. To ensure data validity, validators cross-checked the encoded data with those recorded in the questionnaires. Moreover, encoded data were further updated and reviewed for corrections through computer validation. Data cleaning, checking for consistency and data processing were done by region. All regional files were then merged to create a master file for adults and children. Further checking for consistencies were also done for all the variables by comparing extreme values obtained against valid values for the variable. Weights were assigned and attached to the cleaned data so that the distributions of the sample correspond more closely to their actual distributions in the population as a whole. Strata version 7 was used to estimate the prevalence of disease and risk factors studied. Prevalence according to age and gender was calculated. Whenever possible, estimates of disease prevalence were corrected for false positive and false negative results of the instruments used. True disease prevalence was calculated using the Marchevsky formula: P = A (100% - Sp) , Sn (100% - Sp)

made for false positive and false negative results.

RESULTS A total of 2,636 households from 17 regions and 79 provinces were covered between August to December 2003. The survey covered all the members of the randomly selected households consisting of 2,735 children aged 019 years and 4,753 adults aged 20 years and over. This report deals with cardiovascular disease and risk factors for adults aged 20 or more. Prevalence of atherosclerotic diseases. Tables 1 3 summarize the prevalence rates of atherosclerotic disease in 3 major arterial beds including the coronaries, the cerebral vessels, and the peripheral arteries. The overall prevalence of CAD based on a previous diagnosis was 1.8%. As expected, this increased with age, and was higher among males. In contrast, anginal symptoms were present in 12.5% of subjects. It was more common in women than men, reaching a peak at the 4th decade in both sexes, and declining slightly after, probably because of declining physical activity. A similar pattern was seen with peripheral arterial disease. When based on an objective test (ABI < 0.9) the overall prevalence was 5.0%, with a steady rise
Table 1 . Prevalence of CAD by Age and Gender, Based on Previous Diagnosis, and Based on the PHA Angina Questionnaire, Philippines, 2003.

Gender/Age (y)

Prevalence Based on Previous Diagnosis of CAD% (S.E.) 0.8 (1.0) 0.7 (1.0) 1.5 (1.0) 1.8 (1.0) 3.4 (1.0) 3.6 (1.0) 1.2 (0.0) 0 (0.0) 2.2 (1.0) 2.4 (1.0) 3.9 (2.0) 5.7 (1.0) 5.4 (1.0) 2.4 (0.0) 1.8 (0.0)

Prevalence Based on Angina Questionnaire * % (S.E.) 9.1 (1.5) 9.3 (1.5) 17.8 (2.2) 9.9 (2.1) 13.9 (1.4) 13.0 (1.7) 10.9 (0.7) 7.7 (1.5) 14.2 (2.0) 22.5 (2.5) 11.6 (2.0) 23.0 (1.5) 13.9 (1.5) 14.1 (0.7) 12.5 (0.5)

Male 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subotal Overall

where P is the estimated true prevalence in percent, A is the crude prevalence in percent as determined by the survey instrument, and Sn and Sp are its sensitivity and specifity 8,9 . As can be seen from this formula, adjustments were only possible when both A and Sn are greater than (100 Sp). Otherwise, a negative prevalence would be predicted. This meant that when the prevalence by questionnaire was rare (A is low), then Sp should be very high. This relationship only held true for hypertension and angina, so these are the only 2 situations where corrections were

* Based on the questionnaire (see appendix A), a subject was diagnosed as having angina if there was a history of chest pain, heaviness or tightness, that occurs on exertion, and is relieved by rest or nitrates . The prevalence was adjusted for false positives and false negative results using the Marchevsky equation.

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PJC Vol. 33, No. 2 April - June 2005 Table 3 . Prevalence of Stroke by Age and Gender, Based on Previous Diagnosis and Based on the Philippine Neurological Association Stroke Questionnaire, Philippines, 2003

Table 2 . Prevalence of Peripheral Arterial Disease (PAD) by Age and Gender, Based on Previous Diagnosis of PAD, Based on Ankle-Brachial Index (ABI), and Based on the Claudication Questionnaire, Philippines, 2003

Prevalence based on previous diagnosis of Gender/Age (y) PAD% (S.E) Male 40-49 50-59 60-69 > 70 Subtotal Female 40-49 50-59 60-69 > 70 Subtotal Overall

Prevalence based on ABI*% (S.E)

Prevalence Based on Claudication Questionnaire **% (S.E)

Gender/Age (y)

Prevalence Based on Previous Diagnosis of Stroke% (S.E)

Prevalence Based on Stroke Questionnaire *% (S.E)

0.3(0.3) 0.0(0.0) 0.1(0.1) 0.0(0.0) 0.2(0.1) 1.7(1.0) 0.4(0.4) 0.4(0.2) 0.9(0.4) 0.6(0.2) 0.4(0.1)

1.2 (0.7) 4.0 (1.9) 5.9 (1.0) 10.5 (1.8) 2.9 (0.5) 5.5 (1.5) 4.1 (1.5) 7.2 (1.1) 11.2 (1.4) 7.3 (0.7) 5.0 (0.5)

6.5 2.5 6.3 5.0 4.5 6.1 3.4 4.6 4.4 3.9 4.2

(2.0) (1.0) (1.0) (1.0) (1.0) (2.0) (1.0) (1.0) (1.0) (1.0) (0.0)

* In this study, peripheral arterial disease was defined as an ABI < 0.9 ** Based on the questionnaire, a subject was diagnosed as having claudication if there was a history of calf pain on exertion relieved by rest. No adjustments were made for false positive and false negative results.

Male 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Overall

0.3 0.0 0.9 3.2 6.1 9.1 1.3 0.0 0.0 1.8 2.8 6.0 4.6 1.5 1.4

(0.0) (0.0) (1.0) (1.0) (1.0) (2.0) (0.0) (0.0) (0.0) (1.0) (1.0) (1.0) (1.0) (0.0) (0.0)

0.6 1.0 2.8 3.1 7.5 8.4 2.1 0.3 0.9 2.1 1.0 5.7 6.2 1.7 1.9

(0.4) (0.5) (1.0) (1.2) (1.0) (1.6) (0.3) (0.3) (0.6) (0.8) (0.6) (1.0) (1.1) (0.3) (0.2)

* Based on the questionnaire (see appendix B), a subject was diagnosed as having a stroke if there was a history of sudden weakness, heaviness or numbness on one side or part of the body; or slurred speech, lasting more than 24 hours. No adjustments were made for false positive and false negative results.

Table 4. Mean Total Cholesterol (mg/dL) and Prevalence of Various Levels of Total Cholesterol, by Age and Gender, Philippines: 2003

Gender/ Age Mean mg/dl (S.E) Male 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Overall <160 % (S.E)

Distribution of Total Cholesterol (mg/dL) Levels 160-199 % (S.E) 200-239 % (S.E) > 240% (S.E)

170.7 (1.61) 180.6 (1.70) 185.2 (2.13) 185.2 (3.34) 185.0 (1.79) 177.8 (1.98) 178.9 (0.98) 173.9 (1.73) 182.5 (1.98) 195.9 (2.52) 215.0 (3.36) 208.6 (1.69) 209.1 (2.22) 190.3 (1.13) 184.4 (0.83)

41.5 29.5 27.3 31.1 29.4 36.1 33.2 38.0 26.3 15.6 13.5 14.3 11.9 24.2 28.8

(3.0) (2.0) (3.0) (4.0) (2.0) (2.0) (1.0) (3.0) (3.0) (2.0) (3.0) (1.0) (1.0) (1.0) (1.0)

46.5 46.4 43.0 39.6 43.1 38.6 44.7 46.6 49.4 40.7 24.8 30.0 33.6 41.5 43.2

(3.0) (3.0) (3.0) (4.0) (2.0) (3.0) (1.0) (3.0) (3.0) (3.0) (3.0) (2.0) (2.0) (1.0) (1.0)

8.8 (1.0) 18.7 (2.0) 22.1 (3.0) 19.3 (3.0) 18.9 (2.0) 18.4 (2.0) 16.3 (1.0) 12.0 17.2 32.0 33.7 34.5 33.6 22.9 19.5 (2.0) (2.0) (3.0) (4.0) (2.0) (2.0) (1.0) (1.0)

3.2 5.4 7.6 9.9 8.6 7.0 5.8

(1.0) (1.0) (3.0) (3.0) (2.0) (2.0) (1.0)

3.4 (1.0) 7.1 (2.0) 11.6 (2.0) 28.0 (3.0) 21.2 (2.0) 20.8 (2.0) 11.5 (1.0) 8.5 (1.0)

noted with age. When based on symptoms as determined by the claudication questionnaire, prevalence was 4.2%. Like angina, this peaked at the 4th decade and declined slightly thereafter. However, no significant gender differences were noted. For stroke, based on a previous diagnosis, the prevalence was 1.4%. Based on a history of suggestive symptoms, the prevalence rate was 1.9%. Both

rates increased with age. Like peripheral arterial disease, no significant gender differences were noted. Prevalence of risk factors for atherosclerosis. Table 4 12 summarize the prevalence rates for 5 risk factors including 1) various forms of dyslipidemia, 2) diabetes or impaired fasting glucose (IFG), 3) hypertension, 4) smoking, and 5) various degrees of obesity. In general,

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total cholesterol, LDL and triglyceride levels rose with age, peaking between 40 and 70 years old, then decreasing slightly thereafter. Mean total and LDL cholesterol levels were slightly higher in women (190.3 and 126.8 mg/dL respectively) than in men (178.9 and 112.4 mg/dL respectively). In contrast, mean triglyceride levels were higher in men (130.5 mg/dL) than in women (104.6 mg/ dL). HDL levels did not vary significantly between sexes, and between various age groups (tables 4 7). The overall prevalence of diabetes based on fasting

blood sugar (FBS) levels more than 125 mg/dL was 3.4%, peaking at ages 50-59 with a prevalence of 8.9% (table 8). When the definition was broadened to include patients with normal FBS but with a previous diagnosis of diabetes, overall prevalence was 4.6%, again peaking between the ages of 50 and 59 (10.4%). No significant gender differences were noted. Based on a single visit blood pressure determination > 140/90 mmHg, the prevalence of hypertension was 22.5%. This decreased to 17.4% when the hypertension

Table 5. Mean LDL-Cholesterol (mg/dL) and Prevalence of Various Levels of LDL-Cholesterol, by Age and Gender, Philippines: 2003

Distribution of LDL-C (mg/dL) Levels Age, years Male 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Overall Meanmg/dl (S.E) <130 %(S.E) 130-159 % (S.E) 160-189% (S.E) > 190% (S.E)

106.4 (1.52) 113.1 (1.49) 115.5 (1.97) 117.6 (2.96) 120.7 (1.64) 116.7 (1.77) 112.4 (0.89) 112.7 (1.60) 121.1 (1.76) 131.2 (2.16) 147.6 (3.06) 141.2 (1.51) 141.6 (1.96) 126.8 (1.03) 119.4 (0.76)

85.0 75.2 69.4 67.9 66.5 70.9 75.9 79.4 70.5 51.6 33.0 41.7 41.7 60.8 68.6

(2.0) (2.0) (3.0) (4.0) (2.0) (3.0) (1.0) (3.0) (3.0) (3.0) (3.0) (3.0) (3.0) (2.0) (1.0)

11.5 18.8 19.5 18.8 21.2 16.3 16.7 15.4 19.4 30.8 30.3 28.6 29.1 23.0 19.8

(2.0) (2.0) (3.0) (3.0) (2.0) (2.0) (1.0) (2.0) (2.0) (3.0) (4.0) (2.0) (2.0) (1.0) (1.0)

1.9 (1.0) 4.6 (1.0) 8.2 (2.0) 10.5 (3.0) 8.0 (1.0) 10.0 (2.0) 5.4 (1.0) 3.7 (1.0) 6.7 (2.0) 11.4 (2.0) 24.0 (3.0) 19.9 (2.0) 19.5 (2.0) 10.7 (1.0) 8.0 (1.0)

1.5 1.3 2.9 2.8 4.3 2.8 2.0

(1.0) (1.0) (1.0) (1.0) (1.0) (1.0) (0.0)

1.5 (1.0) 3.4 (1.0) 6.1 (2.0) 12.7 (2.0) 9.9 (1.0) 9.8 (2.0) 5.4 (1.0) 3.7 (0.0)

Table 6.

Mean HDL-Cholesterol (mg/dL) and Prevalence of Various Levels of HDL-Cholesterol, by Age and Gender, Philippines: 2003

% Distribution of HDL-C (mg/dL) levels Age, years Male 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Overall 40.8 (0.46) 40.3 (0.40) 40.2 (0.54) 38.6 (0.51) 39.9 (0.30) 40.0 (0.40) 40.3 (0.24) 43.2 (0.52) 42.1 (0.47) 42.8 (0.59) 42.4 (0.62) 42.1 (0.34) 42.4 (0.42) 42.6 (0.24) 41.4 (0.19) 55.4 62.5 60.2 67.8 61.7 59.3 60.2 (3.0) (2.0) (3.0) (4.0) (2.0) (3.0) (2.0) 19.7 16.1 18.0 19.8 18.8 19.8 18.2 19.9 22.2 17.1 26.0 16.9 14.4 20.2 19.2 (2.0) (2.0) (2.0) (4.0) (2.0) (2.0) (1.0) (3.0) (2.0) (2.0) (4.0) (1.0) (2.0) (1.0) (1.0) 12.6 (2.0) 8.5 (2.0) 9.4 (2.0) 7.5 (2.0) 8.7 (1.0) 8.9 (2.0) 9.9 (1.0) 15.6 10.7 12.4 13.4 11.3 14.5 13.0 11.4 (2.0) (2.0) (2.0) (3.0) (1.0) (2.0) (1.0) (1.0) 5.0 6.6 5.8 2.1 5.5 6.8 5.5 (1.0) (1.0) (2.0) (1.0) (1.0) (1.0) (1.0) 4.4 3.8 3.6 1.3 3.4 2.8 3.6 3.2 3.8 6.6 5.1 6.1 4.4 4.5 4.1 (1.0) (1.0) (1.0) (1.0) (1.0) (1.0) (1.0) (1.0) (1.0) (2.0) (2.0) (1.0) (1.0) (1.0) (0.0) 2.9 2.6 3.0 1.4 1.9 2.4 2.6 7.9 4.4 5.4 5.2 5.3 5.4 5.8 4.1 (1.0) (1.0) (1.0) (1.0) (1.0) (1.0) (1.0) (2.0) (1.0) (2.0) (2.0) (1.0) (1.0) (1.0) (0.0) Mean mg/dl (S.E) < 40% (S.E) 40 44% (S.E) 45-49% (S.E) 50-54% (S.E) 55-59% (S.E) > 60% (S.E)

44.4 (3.0) 49.7 (3.0) 48.6 (3.0) 44.8 (4.0) 52.7 (2.0) 50.5 (3.0) 47.7 (1.0 54.2 (1.0)

9.0 (2.0) 9.2 (2.0) 9.9 (2.0) 5.5 (2.0) 7.6 (1.0) 10.7 (2.0) 8.8 (1.0) 7.1 (1.0)

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Table 7. Mean Triglyceride (mg/dL) and Prevalence of Various Levels of Triglyceride, by Age and Gender, Philippines: 2003

Distribution of Triglycerides (mg/dL) Levels Age, years Male 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Overall 116.6 (3.5) 135.7 (4.3) 147.1 (5.3) 145.1 (9.3) 121.6 (3.2) 105.6 (2.9) 130.5 (2.3) 89.5 (2.5) 96.3 (2.7) 109.4 (4.1) 125.4 (4.6) 126.8 (2.5) 124.8 (3.1) 104.6 (1.4) 118.0 (1.41) 79.8 69.6 66.8 67.2 80.3 90.1 73.5 92.2 89.0 84.3 74.2 76.9 79.9 85.7 79.4 (2.0) (3.0) (3.0) (4.0) (2.0) (2.0) (1.0) (2.0) (2.0) (3.0) (3.0) (2.0) (2.0) (1.0) (1.0) 11.6 (2.0) 15.5 (2.0) 15.6 (3.0) 15.1 (3.0) 10.7 (1.0) 5.0 (1.0) 13.6 (1.0) 4.9 (1.0) 8.3 (2.0) 9.8 (3.0) 12.4 (3.0) 13.6 (1.0) 11.7 (2.0) 8.8 (1.0) 11.2 (1.0) 7.9 (2.0) 14.2 (2.0) 15.3 (2.0) 15.9 (4.0) 7.9 (1.0) 4.6 (1.0) 11.8 (1.0) 2.9 (1.0) 2.8 (1.0) 5.7 (2.0) 12.7 (2.0) 9.0 (1.0) 6.8 (1.0) 5.3 (1.0) 8.7 (1.0) 0.8 0.7 2.3 1.7 1.2 0.3 1.1 (1.0) (0.0) (1.0) (1.0) (1.0) (0.0) (0.0) Mean mg/dl (S.E) <150% (S.E) 150-199% (S.E) 200-399% (S.E) > 400% (S.E)

0 (0.0) 0 (0.0) 0.3 (0.0) 0.7 (1.0) 0.6 (0.0) 1.6 (1.0) 0.2 (0.0) 0.7 (0.0)

Table 8. Prevalence of Impaired Fasting Glucose (IFG) and Diabetes Mellitus (DM) Based on Fasting Blood Sugar (FBS) and Based on a Diabetes Questionnaire, by Age and Gender, Philippines 2003.

Table 9. Prevalence of Hypertension Based on a Single Visit Blood Pressure and Based on the Hypertension Questionnaire, by Age and Gender, Philippines 2003.

Age, years

Impaired Fasting Glucose* % (SE)

Prevalence of Diabetes Mellitus Based on DM Based on FBS ** questionnaire *** % (SE) % (SE) Male 1.8 2.4 6.5 9.4 6.5 7.6 4.1 (1.0) (1.0) (1.0) (2.0) (1.0) (1.0) (1.0)

Age, years

Prevalence Based on a Single Visit BP % (S.E)

Prevalence Based on the Hypertension Questionnaire *% (S.E)

Male 20-29 30-39 40-49 50-59 60-69 >70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 >70 Subtotal Overall

1.7 2.3 4.6 7.4 4.8 4.2 3.2 0.5 1.9 5.4 4.3 6.3 7.4 3.2 3.2

(1.0) (1.0) (2.0) (2.0) (1.0) (1.0) (1.0) (0.0) (1.0) (1.0) (2.0) (1.0) (1.0) (0.0) (0.0)

0.9 2.2 5.2 8.6 5.0 4.8 3.2 0.4 1.9 4.6 9.1 7.3 5.2 3.5 3.4

(1.0) (1.0) (2.0) (2.0) (1.0) (1.0) (1.0) (0.0) (1.0) (2.0) (2.0) (1.0) (1.0) (1.0) (0.0)

20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Overall

13.0 (2.0) 19.1 (2.0) 29.6(2.0) 41.1 (3.0) 44.3 (2.0) 50.8 (3.0) 24.2(1.0) 3.7 (1.0) 8.1 (1.0) 23.1 (2.0) 39.8 (3.0) 47.0(2.0) 59.3(2.0) 20.8(1.0) 22.5 (1.0)

4.0 (2.5) 11.5 (3.4) 26.1 (4.3) 38.3 (5.1) 44.8 (2.8) 54.8 (2.6) 18.4 (1.3) Not applicable 0.7 (1.3) 21.6 (4.4) 39.0 (4.6) 51.2 (2.4) 62.3 (2.5) 16.5 (1.1) 17.4 (0.9)

0.5 (0.0) 2.7 (1.0) 5.2 (2.0) 11.2 (2.0) 10.8 (1.0) 9.3 (1.0) 5.0 (1.0) 4.6 (0.0)

* Impaired fasting glucose was defined as a fasting glucose level of 100-125 mg/dL. ** Diabetes was defined as a fasting glucose level > 125 mg/dL. ** Based on the DM questionnaire, a subject has diabetes if FBS is > 125, Or if there was a previous diagnosis by a nurse or physician.

* Based on the hypertension questionnaire, a subject was diagnosed as having hypertension if SBP was > 140, DBP was > 90, OR if there was a previous diagnosis by a nurse or physician. The prevelance was adjusted for false positives and false negative results using the Marchevsky equation.

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questionnaire was used because this questionnaire predicted the prevalence of hypertension based on two blood pressure determination taken on separate days (table 9). Using either definition, the prevalence of hypertension peaked in the age group 60 69 years old. Current smoking, by far, was the most common risk factor, with a prevalence of 12.1% among women, and 56.3% among men. The overall prevalence was 34.8%. For women, a steady rise in smoking prevalence was noted from ages 20-29 (7.3%) to ages 70 or more (22.4%). For men, the prevalence was more or less constant across all age groups. In addition, 15.1% of men and 5.1% of women were former smokers. Based on BMI > 30, the prevalence of obesity was only 3.2% in men and 6.6% in women. When WHR criteria were used, the prevalence rates were 12.1% and 54.8% respectively. These data suggest that abdominal obesity using the waist-to-hip ratio is an important criterion for obesity among Asians in general and Filipinos in particular.

DISCUSSION Using various criteria, Table 13 compares the prevalence of coronary, cerebrovascular and peripheral arterial disease in NNHeS, with the 1998 survey of the NNS 10 . Also shown for comparison are the results of a study done in the United States in 2002, which used a
Table 10. Prevalence of Never, Current and Former Smoking, by Age and Gender, Philippines 2003.

similar design and criteria 11,12. Based on symptomatology, the incidence of stroke and angina remained almost the same in these two time periods. No data on peripheral arterial disease symptoms was available in 1998. Based on a history of previous diagnoses, the US data reported higher prevalence rates for all 3 diseases. This may mean a higher prevalence of disease, or may simply mean a higher rate of diagnosis resulting from greater access to health care. Similarly, Table 14 compares the prevalence rates of 5 risk factors (dyslipidemia, diabetes, hypertension, smoking and obesity). In general, the prevalence of these risk factors did not change significantly between the 2 time periods. Dyslipidemia defined as a total cholesterol > 240 mg/dL seemed to rise from 4% to 8.5%, but this could be due to a difference in the laboratory methods used. The 1998 survey used a capillary method, while the 2003 survey used a whole blood. As expected, the prevalence of dyslipidemia and obesity were markedly higher in the US. Hypertension and diabetes rates, on the other hand, were very similar in the 2 countries. Smoking was the only risk factor more prevalent in the Philippines than in the USA.

Age, years

Never % (S.E)

Level of Smoking Current % (S.E)

Former % (S.E)

Male 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Female 20-29 30-39 40-49 50-59 60-69 > 70 Subtotal Overall

34.5 (3.0) 31.9 (2.0) 25.4 (3.0) 15.8 (3.0) 19.4 (2.0) 22.4 (2.0) 28.6 (1.0) 89.0 89.1 83.4 79.6 64.9 60.2 82.8 55.0 (2.0) (2.0) (2.0) (3.0) (2.0) (2.0) (1.0) (1.0)

58.8 54.2 61.0 59.5 48.6 35.9 56.3

(3.0) (3.0) (3.0) (4.0) (2.0) (2.0) (1.0)

6.7 (1.0) 14.0 (2.0) 13.6 (2.0) 24.7 (3.0) 32.1 (2.0) 41.8 (3.0) 15.1 (1.0) 3.7 (1.0) 2.4 (0.0) 4.6 (2.0) 4.4 (1.0) 11.3 (1.0) 17.5 (2.0) 5.1 (1.0) 10.2 (1.0)

7.3 (2.0) 8.5 (2.0) 12.1 (2.0) 16.1 (2.0) 23.8 (2.0) 22.4 (2.0) 12.1 (1.0) 34.8 (1.0)

CONCLUSION In summary, we have reported the prevalence of atherosclerotic disease of the coronary, cerebrovascular and peripheral arterial bed in the Philippines. We have also reported the prevalence of 5 risk factors for these diseases. The prevalence of dyslipidemia and diabetes remained relatively low, while hypertension remained relatively high. Obesity by WHR was much more common than obesity by BMI. Smoking, by far, was the most common risk factor found. These data on atherosclerosis-related diseases and risk factors from the NNHeS provide clinicians and policymakers a birds eye view of the Philippine situation with respect to vascular disease and its risk factors. These data may be used for policy formulation and program prioritization. In addition, the information may serve as baseline measures to evaluate the success or failure of atherosclerosis control programs in the country. A 2nd NNHeS is planned in the year 2008.
Acknowledgment The authors would like to thank Ms. Josephine Sanchez and Ms. Tess Mararac for facilitating the writing

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Table 11. Percentage Distribution of Various Levels of Body Mass Index (BMI), Based on the WHO Criteria for Overweight and Obesity, by Age and Gender, Philippines 2003.

Sex / Age

Chronic Energy Deficient(< 18.5)% (S.E)

Low Normal (18.5 -19.9) % (S.E)

Normal (20.0 -24.9) % (S.E)

Overweight (25.0 - 29.9) % (S.E)

Obese (30.0 -39.9) % (S.E)

Male 20-29 30-39 40-49 50-59 60-69 70 &over Subtotal Female 20-29 30-39 40-49 50-59 60-69 70 &over Subtotal Overall 11.0 (1.7) 7.3 (1.3) 9.7 (1.9) 12.4 (2.3) 23.6 (1.8) 28.1 (2.6) 11.1 (1.1) 18.4 (2.4) 8.0 (1.5) 11.4 (2.0) 10.3 (1.9) 19.5 (1.5) 28.1 (2.2) 13.7 (1.3) 12.4 (0.7) 14.0 14.2 11.1 13.1 12.3 22.1 13.6 (2.0) (2.0) (2.0) (2.0) (1.0) (2.0) (1.0) 60.6 53.8 48.9 45.8 46.6 41.7 53.3 47.3 54.8 43.4 44.7 39.6 37.2 47.1 50.2 (3.0) (3.0) (3.0) (3.0) (2.0) (3.0) (1.0) (3.0) (3.0) (3.0) (4.0) (2.0) (2.0) (1.0) (1.0) 12.9 (2.0) 20.5 (2.0) 26.0 (3.0) 24.1 (3.0) 15.1 (2.0) 7.2 (1.0) 18.8 (1.0) 11.5 19.9 30.9 26.4 22.0 14.7 20.5 19.6 (2.0) (2.0) (3.0) (3.0) (2.0) (2.0) (1.0) (1.0) 1.5 (1.0) 4.1 (1.0) 4.1 (1.0) 4.7 (2.0) 2.3 (1.0) 0.8 (1.0) 3.2 ( 0.0) 5.3 (1.0) 6.1 (1.0) 7.2 (2.0) 11.0 (2.0) 4.6 (1.0) 3.3 (1.0) 6.6 (1.0) 4.8 ( 0.0)

17.4 (2.0) 11.2 (2.0) 7.0 (2.0) 7.6 (2.0) 14.3 (1.0) 16.7 (2.0) 12.1 (1.0) 12.9 (1.0)

Table 12. Mean Waist-Hip Ratio (WHR), and Distribution of Various Levels of WHR, by Sex and by Age, Philippines, 2003

Mean WHR % (S.E) Sex/Age Male 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 &over Total 0.88 0.91 0.93 0.94 0.93 0.91 0.91 (0.0) (0.0) (0.0) (1.0) (0.0) (0.0) (0.0)

Distribution of Various Levels of WHR IN % (SE) > 1.0 0.9 - 0.99 < 0.9 % (S.E) % (S.E) % (S.E)

58.1 39.8 27.3 21.2 30.3 39.9 40.6

(3.0) (3.0) (3.0) (3.0) (2.0) (3.0) (2.0)

35.9 ( 3.0) 48.5 ( 3.0) 57.6 ( 3.0) 58.0 ( 4.0) 50.9 ( 2.0) 46.4 ( 3.0) 47.3 ( 1.0) 0.8 - 0.84 % (S.E) 33.8 37.6 24.2 21.0 22.0 20.2 29.4 (3.0) (3.0) (3.0) (3.0) (2.0) (2.0) (1.0)

6.0 (1.0) 11.7 (2.0) 15.1 (2.0) 18.8 (2.0) 20.8 (3.0) 13.7 (2.0) 12.1 (1.0) > 0.85 % (S.E) 38.7(3.0) 49.6 (3.0) 66.2 (3.0) 70.0 (3.0) 64.4 (2.0) 62.0 (2.0) 54.8 (2.0)

Female 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 &over Total 0.83 0.85 0.87 0.88 0.87 0.88 0.85 (0.0) (0.0) (0.0) (1.0) (0.0) (1.0) (0.0)

< 0.8 % (S.E) 27.5 (3.0) 12.8 (2.0) 9.5 (2.0) 9.0 (2.0) 13.6 (1.0) 17.8 (2.0) 15.8 (1.0)

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Table 13. Comparison of Prevalence Rates for Coronary, Cerebrovascular and Peripheral Arterial Disease in the Philippines in 2003 and 1998, and in the USA in 2002.

Philippines 2003 Coronary Disease Anginal symptoms Previous diagnosis of Ischemia Cerebrovascular disease Stroke symptoms Previous diagnosis of stroke Peripheral arterial disease Claudication symptoms Previous diagnosis of PAD 1998

United States 2002

12.5% 1.8%

12.9% -

6.1 %

1.9% 1.4%

2.3 %

4.2% 0.4%

4.3 %

Table 14. Comparison of Prevalence Rates for Dyslipidemia, Diabetes, Hypertension, Smoking and Obesity in the Philippines in 2003 and 1998, and in the USA in 2002.

Philippines 2003 Dyslipidemia based on Total Cholesterol > 240 mg/dL Diabetes based onFasting glucose > 125 mg/dL Hypertension based onSingle BP > 140/90 mmHg Smoking based onHistory of current smoking Obesity based onBMI > 30 kg/m2 8.5% 3.4 % 22.5 % 34.8 % 5.0 % 1998 4.0% 3.9 % 21.0 % 32.7 % 4.6 %

United states 17.7 % 7.1% 19.8 % 21.6 % 25.6 %

of the manuscript and for helping prepare the tables and drafts. We also like to thank the participants in the study as well as the numerous field workers. This study was funded through major contributions from the Department of Health of the Philippines, Philippine Heart Association, Philippine Lipid Society, Philippine Society of Hypertension, Philippine Diabetes Association and the Food and Nutrition Research Institute of the Department of Science and Technology. Substantial contributions came from the Philippine Pediatric Society, Philippine Society of Nephrology, Philippine Society of Endocrinology and Metabolism, Osteoporosis Society of the Philippines, Philippine Association for the Study of Overweight and Obesity, Philippine Neurological Association, and Philippine Rheumatology Association. Other contributions were from the Philippine College of Physicians, Philippine Society of Gastroenterology and Philippine Society of Asthma, Allergy and Immunology.

2.

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1. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part I: General considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2003;104(22):2746-53

Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part II: Variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2003;104(23):2855- 64 3. Reddy S, Yusuf S. Emerging Epidemic of Cardiovascular Disease in Developing Countries. Circulation 1998;97:596601 4. Dans AL et al. for the Ad Hoc Committee on CAD Surveillance. A surveillance system for cardiovascular disease in developing countries: Development of a questionnaire for angina (completed 1998). Unpublished 5. Dans AL, MT Abola, MVC Villarruz. Prevalence of Peripheral Arterial Disease in the Philippines Phase 2: A survey on the Prevalence of PAD using the Edinburgh Claudication Questionnaire. ASEAN Heart Journal Vol.11 No.1 January June 2004; pp 24-28 6 . Transatlantic Inter-society Consensus Statement on Management of PAD. Journal of Vascular Surgery January 2000 , Part 2. Vol. 31, No. 1 7. Executive summary of the Third report of the National Cholesterol Education Program (NCEP). Expert panel on detection, evaluation and treatment of high blood cholesterol in adults (Adults, Treatment, Panel III). JAMA 2001 285:2486 8. Marchevsky N. Errors in prevalence estimates in population studies:A practical method for calculating real prevalence. Zoonosis 1974;16:98-109 9. Rogan WJ, Gladen B. Estimating prevalence from the results of a screening test. Am J Epidemiol 1978, 107:71-76 10. Sy, R., Dans, A. et al. The Prevalence of Dyslipidemia, Diabetes

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Mellitus, Hypertension, Stroke and Angina Pectoris in the Philippines. Phil. J of Intern Med 2003:41;1-6. 11. U.S. Department of Health and Human Services. National Center for Health Statistics. National Health Interview Survey, 2002 (computer file) ICPSR version. Hyattsville, MD: U.S. Department of Health and Human Services, National Center for Health Statistics (producer), 2002. Ann Arbor, MI: Interuniversity consortium for Political and Social Research (distributor), 2005. 12. Results from Center for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

Appendix A: The Philippine Heart Association Angina Questionnaire 1. Have you ever experienced any pain in your chest during the past two years? [ ] Yes [ ] No 2. Have you ever experienced any tightness in your chest during the past two years? [ ] Yes [ ] No 3. Have you ever experienced any heaviness in your chest during the past two years? [ ] Yes [ ] No If the responses to question 3, 4, and 5 are NO, the interview should end. Otherwise, proceed to question 4. 4. When does the sensation usually start? 4.1 During physical exertion? [ ] Yes [ ] No 4.2 or even while resting? [ ] Yes [ ] No 5. Is the sensation usually relieved by rest? [ ] Yes [ ] No 6. Is the sensation usually relieved by sublingual medication? [ ] Yes [ ] No Angina was considered present if: 1. A Yes to either 1, 2, or 3 AND 2. A Yes in 4.1 AND 3. A Yes in 5 OR A Yes in 6 Appendix B: The Stroke Questionnaire Have you ever experienced any of the following? 1. Sudden weakness, heaviness or numbness on ONE SIDE or part of the body ? ( For example: sudden face, arm or leg weakness or numbness) [ ] Yes [ ] No 1.1 If answer in number 1 is yes, did the weakness, heaviness or numbness last for more than 24 hours? [ ] Yes [ ] No 2. Sudden slurring of speech or inability to say what you want to say ? [ ] Yes [ ] No 2.1 If answer in number 2 is yes, did the slurring last for more than 24 hours? [ ] Yes [ ] No

Stroke was considered present for any of the following responses: 1. A Yes to questions number 1 and 1.1, OR 2. A Yes to questions number 2 and 2.1. Appendix C: The Claudication Questionnaire 1. Do you get a pain in your leg(s) when you walk? [ ] Yes [ ] No If you answered Yes to question 1, please proceed answering the following questions;Otherwise, you need not continue. 2. Does this pain ever begin when you are standing still or sitting? [ ] Yes [ ] No 3. Do you get it if you walk uphill or in a hurry? [ ] Yes [ ] No 4. Do you get it when you walk at an ordinary pace on the level? [ ] Yes [ ] No a. What happens to the pain when you stand still? Usually continues more than 10 minutes? [ ] Yes [ ] No b. What happens to the pain if you stand still? Usually disappear in 10 minutes or less? [ ] Yes [ ] No 5. Where do you feel this pain or discomfort? Mark the place(s) with X in the diagram:

Claudication was considered present if: 1. a YES response for questions 1, 3 and 4b and 2. a NO response to question no.2 Appendix D: Hypertension Questionnaire 1. Have you taken any hypertensive medications in the past 14 days? [ ] Yes [ ] No 2. What is the name of your medication? 1) ____________________________ 2) ____________________________ 3) ____________________________ 2.1 How long have you been taking it? ______________________________ 2.2 At what dosage are you taking it? _____________________________