Research articleCardiovascular disease risk reduction in the Behavioral Risk Factor Surveillance System
Introduction
Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in the United States.1 Mortality and morbidity can be reduced by therapies for CVD risk factors, such as hypertension2 and dyslipidemia,3 or through the use of aspirin.4 Consequently, multiple medical societies, including the U.S. Preventive Services Task Force,5, 6, 7 American Heart Association/American College of Cardiology,8, 9, 10, 11, 12 and American Diabetes Association13 have endorsed guidelines addressing these risk factors. These CVD risk-reduction practices vary with the amount of CVD risk, or CVD risk status. For high-risk patients, or patients with a previous history of CVD or diabetes, CVD risk-reduction practices involve at least annual measurement of lipids, blood pressure, and discussion of aspirin therapy, along with lifestyle recommendations for diet and exercise. For patients at intermediate or low risk for CVD events, CVD risk-reduction practices are based on the actual degree of CVD risk.
Unfortunately, multiple population-based studies indicate that CVD risk-reduction practices are suboptimal, even in populations at high CVD risk.14, 15, 16, 17, 18, 19 This problem may be worse in women.20 Women may undergo diagnostic testing21 and revascularization for coronary disease22 at lower rates compared to men, and it is possible that the mechanisms that produce gender disparities in these areas could lead to gender disparities in other CVD risk-reduction practices as well. Such mechanisms include different patterns of comorbid illness23, 24 between women and men and resulting indications for therapy, and under-recognition of CVD risk by women25 and their clinicians.26
However, the association between gender and appropriate CVD risk-reduction practices is unclear. Several studies suggest that women may receive more or similar intensive screening and treatment for CVD risk factors than men,27, 28, 29 while other studies suggest that women receive less.30, 31, 32, 33 There are several possible explanations for the conflicting results. First, CVD risk-reduction practices could vary between healthcare systems, and gender-associated differences could exist in one system and not another. Second, gender comparisons need to adjust for CVD risk status, since CVD risk-reduction practices are based on CVD risk. Unadjusted comparisons may have obscured any gender differences in some studies, especially those in people at lower CVD risk who did not have a diagnosis of a CVD event or diabetes to “trigger” appropriate risk-reduction practices. Third, since women may be more frequent users of the healthcare system,34 gender differences in CVD risk-reduction practices may occur more frequently for practices that focus on behavior outside the office such as aspirin use, compared to preventive clinical services delivered within the healthcare system. Finally, healthcare practices evolve with time and it is possible that any disparities documented in the early 1990s may have since narrowed.35
Therefore, given the somewhat conflicting results of previous studies examining gender differences in CVD risk-reduction practices, the association between gender and several CVD risk-reduction practices in 97,387 participants in the 1999 Behavioral Risk Factor Surveillance System (BRFSS) was examined.36 The primary hypothesis was that after adjustment for CVD risk status, men would report greater frequency of CVD risk-reduction practices than women. In other words, after adjustment for CVD risk status, men would report lipid and blood pressure monitoring, receipt of physician advice to exercise and eat less fat and cholesterol, aspirin use, and exercising and eating less fat and cholesterol more often than women.
Section snippets
Data sources and collection procedures
The BRFSS is a federally funded survey designed by the Centers for Disease Control and Prevention (CDC) and implemented in collaboration with state health departments. Random-digit-dial methods were used to derive a probability sample of households with telephones to collect data on health-related behaviors and risk factors for non-institutionalized civilians aged ≥18 years.
The BRFSS has a set of core questions asked by all of the states (called “core”), and a set of optional questions used by
Results
Of the 97,387 participants, 38,839 were men and 58,548 were women. Characteristics of men and women are illustrated in Table 1. Women were slightly older, more often African American, less educated, and had lower incomes than men. Women also reported a greater number of days of poor physical health and more recent checkups than men. A greater proportion of men were at high CVD risk (Table 1).
Table 2 shows the unadjusted prevalences of CVD risk-reduction practices in men and women, stratified by
Discussion
In this analysis, the frequency of CVD risk-reduction practices increased with CVD risk. However, not all CVD risk-reduction practices were performed optimally. While cholesterol and blood pressure measurements were performed for the majority of people at high risk for CVD, only about three quarters of people at high risk reported lifestyle modification, and only about half used aspirin. In addition, despite literature suggesting that women may experience fewer and less frequent CVD
Acknowledgements
CK received funding via an American Diabetes Association Junior Faculty Award.
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