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| Journal of the New Zealand Medical Association,
17-November-2006, Vol 119 No 1245
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Trends in major cardiovascular risk factors in Auckland,
New Zealand: 1982 to 2002-2003
Patricia Metcalf, Robert Scragg, David Schaaf, Lorna Dyall,
Peter Black, Rod Jackson
Coronary heart disease, other diseases of the heart, and
cerebrovascular disease are the leading causes of death in New
Zealand.1 The death rates for coronary heart
disease and stroke have been declining since the
1970s.2 Part of this decline is attributed to
reductions in cardiovascular disease risk factor levels and increased
treatment.3
Three previous cross-sectional surveys (the 1982 Auckland
Risk Factor Study, the 1986-1988 Heart Study, and the 1993–1994 Auckland
Heart and Health Study) conducted in the Auckland area measured cardiovascular
risk factors and described their trends over time in
non-Māori and
non-Pacific people.3–5 These
studies demonstrated a decline in the prevalence of untreated and under treated
raised blood pressure,3 together with a
decrease in blood pressure levels. The reduction in mean blood pressure levels
was not explained by increased drug treatment, but may have been due to
increased leisure time physical activity.6
These studies also showed a clear reduction in the prevalence of self-reported
cigarette smoking, and mean serum total cholesterol levels in Aucklanders aged
35–64 years.5
This report updates these previous surveys and describes the
trends in cardiovascular disease risk factor levels from 1982 to 2002-2003 in
Auckland.
MethodsThree cross-sectional surveys
measuring cardiovascular risk factors have been undertaken in the Auckland
metropolitan area since 1982 as part of the World Health Organization MONICA
project. The methodology has been fully described
elsewhere.4,5 The initial study was the 1982
Auckland Risk Factor Study involving 1568 people aged 35 to 64 years.
In 1986–88, 888 people aged 35–64 years
participated in the Auckland Heart Study; and in 1993–94, 1893 people aged
35–74 years were involved in the Auckland Heart and Health Study. In each
survey, age- and gender-stratified random samples were
selected from the
Auckland general electoral rolls. Response rates in these three studies were
between 72% and 85%. Māori were excluded because approximately half were
enrolled on the Māori electoral roll and those on the general roll were not
considered to be
representative
of all Māori. Other non-Europeans were excluded from the analyses because
of small numbers and concern regarding their incomplete electoral roll
registration.
The fourth study, the Auckland Diabetes, Heart and
Health Survey, was carried out between December 2001 and November 2003. Adults
aged 35–74 years were recruited from 2 sampling frames: one was a cluster
sample where random starting point addresses were obtained from Statistics New
Zealand and the probability of selection was proportional to the number of
people living in that mesh block (response rate 61.3%); and the other was a
random sample taken from the November 2000 Auckland electoral rolls stratified
into 5-year age bands and included all people living in the Auckland area, but
excluding Franklin and Rodney (response rate 60%).
Out
of the 2024 non-Māori and non-Pacific participants interviewed, 942 were
from the cluster sample, and 1082 were from the electoral roll. Māori and
Pacific participants were not included in this report because there is no
historical data to compare them to. However, the data collected will provide
baseline data for future surveys.
Ethical Committee approval was obtained from the
Auckland Ethics Committees. Similar standardised data collection methods were
used in all four surveys. In the first three surveys, interviews were carried
out at central study centres. In the fourth survey, interviews were carried out
in halls or clinics close to participant’s homes.
Personnel were trained in the administration of the
questionnaires and in taking blood pressure and other measurements. In the first
three surveys, blood pressure was measured twice (5 minutes apart) with
regularly calibrated Hawksley random zero sphygmomanometers, and in the fourth
survey, Omron-Hem-706 oscillometric blood pressure pulse monitors were used. The
Omron monitor read 1.74 mmHg (p=0.04) higher for systolic and 1.26 mmHg higher
for diastolic blood pressure (p=0.04) than the random zero sphygmomanometer in a
group of 237 people.
The data have not been adjusted for this difference, so
results will be conservative. Correlations between the two monitors were 0.76
for systolic and 0.82 for diastolic blood pressure levels. Normal and obese cuff
sizes were used in all of the studies.
A person was arbitrarily classified as having raised
blood pressure if the mean of the two measured blood pressures was >150 mmHg
systolic or >90 mmHg diastolic, or if they reported taking medication for
raised blood pressure.
As done previously,6
the population prevalence of raised blood pressure was calculated by classifying
the population into four groups based on blood pressure levels and use of blood
pressure lowering medication:
Serum cholesterol was measured
using the enzymatic methods of Allain et al,7
and HDL-cholesterol was measured using after precipitation of apolipoprotein
B-containing lipoproteins with magnesium
phosphate8 in the first three surveys and using
a combination of a polyion and a divalent cation (Roche) in the last survey. The
latter directly measures HDL-cholesterol and has been shown to estimate levels
0.1 mmol/L higher than for HDL-cholesterol measured by
precipitation.9 Results have not been adjusted
to take account of these differences.
At the time of the 1986–88 survey, it became
apparent that the 1982 cholesterol results were consistently lower than
expected, based on the 1986–88 results. As described elsewhere, repeat
measurement of 200 frozen 1982 serum samples were carried out and the 1982
results have been adjusted using the equation: 0.1352892 + (1.061393 * crude
value).3,5
Cigarette smoking status was self-reported by the
participant using similar questions in all four surveys. The 5-year risks of
cardiovascular disease were calculated according to the New Zealand Guidelines
Group10 for the 2002–3 survey as not all
the required risk factor levels were measured in earlier surveys.
Weight and height were measured to the nearest 0.1 kg
and 0.5 cm, respectively. Body mass index (BMI) was calculated as weight (in kg)
divided by the square of height (in m). Obesity was defined as a body mass index
>30 kg/m2, and overweight as a body mass
index between >25 and 30 kg/m2.
Participant data from the most recent survey were
weighted according to the sampling frame that they were obtained from and means,
standard errors and prevalences calculated using dual frame sampling
methodology.11–13
SAS survey procedures (SURVEYMEANS, SURVEYREG, and
SURVEYFREQ) were used to calculate weighted means, adjusted means and
percentages.14 To make comparisons between the
four surveys, means and prevalence estimates were then directly age standardised
to the 1986 New Zealand population after taking into account the sample design,
and 95% confidence intervals calculated using standard methods.
ResultsMean systolic and diastolic blood
pressure levels for the four surveys in men and women by age groups are reported
in Table 1. In the fourth survey, one person was excluded due to missing blood
pressure measurements and four were excluded as they were outside the age range,
thus leaving 2019.
Figures 1 and 2 show that, in general, in both men and
women, there was a downwards trend in systolic blood pressure levels between
1982 and 2002–03 in all age groups.
For diastolic blood pressure, levels decreased in both men
and women between 1982 and 1993–94, but have since remained approximately
stable.
Table 1. Mean (SE) systolic and diastolic blood
pressure of 2019 participants by age group and gender in the periods of the four
surveys (with 95% confidence intervals)
To examine time trends in the prevalence of raised blood
pressure, the following analyses were restricted to participants aged
35–64 years and prevalence estimates were directly age-standardized to the
1986 New Zealand census population.
Table 2 shows the prevalence of raised blood pressure by
treatment category and by gender for the 1982, 1986-88, 1993-94, and
2002–2003 studies. The proportion of people with untreated blood pressure
levels >150/90 mmHg fell by more than 83% in men and women between 1982 and
2002–03. The total proportion of people with blood pressure levels
<150/90 increased by approximately 20% over the period.
Figure 1. Trends in systolic and diastolic blood
pressure in men by age group
 Figure 2. Trends in systolic and diastolic blood
pressure in women by age group
 The percentage of people on treatment with blood pressure
>150/90 mmHg also declined over the 20-year period, particularly in women.
The proportion of men and women with treated blood pressure below 150/90 mmHg
increased over the period, particularly in men. There was a small increase in
the total prevalence of treatment in men and a small decrease in
women.
Table 2. Age
standardised†
percentage (95% confidence interval) of raised blood pressure among Europeans by
gender for the four surveys
BP=blood pressure;
†Directly age-standardised to the 1986 New Zealand population;
Rx=treatment.
Trends in mean lipid levels and lipid-lowering medication
use in men and women by age group and study year are shown in Table 3. In every
age group for men and women, serum cholesterol levels declined from 1982 to
2002–3, together with a generally increasing trend in levels of
HDL-cholesterol and an approximately decreasing trend in the cholesterol to HDL
ratio. There was also a general trend of increasing use of lipid-lowering
medications over time and with increasing age.
Table 3. Trends in mean (SE) levels of lipids and
lipid-lowering medication use in Auckland men and women by age group in 1982,
1986–8, 1993–4, and 2002–3
†Fasting triglycerides
not measured in the previous surveys.
Table 4 shows trends in mean levels of body mass index (and
Figure 3), weight, height and prevalences of overweight and obesity by age group
and year in men and women. Mean body mass index and weight show increasing
trends over the studies. Mean height remained approximately constant across all
surveys. In 1982, approximately 52.8% of men and 36.5% of women were overweight
or obese; whereas in the 2002–3 survey, 70.9% of men and 57.0% of women
were in these latter categories.
Table 4. Trends in mean (SE) levels of body mass index,
weight, and height—and prevalences of overweight and obesity in Auckland
men and women by age group in 1982,
1986-8†, 1993-4,
2002–3
†Weight and height were
not measured in 1986–8.
Figure 3. Trends in body mass index in men and women by
age group
 Prevalences of self-reported cigarette smoking, ex-smokers,
never smokers, and mean number of cigarettes smoked per day in current smokers
are reported in Table 5. The percentages of current cigarette smokers fell
between 1982 and 1993–4 in both men and women in most age groups, but
there appears to have been little change between 1993–4 and 2002–3.
However, the proportion of never smokers increased between 1982 and 2002-3 in
most age groups, whereas the proportion of ex-smokers increased until 1993-4,
but fell slightly in most age groups subsequently. In general, the number of
cigarettes smoked per day in current smokers appears to be declining.
Trends in leisure time physical activity and prevalences of
previously diagnosed diabetes mellitus are shown in Table 6. There were trends
towards higher moderate exercise, but lower vigorous exercise in 35–44 and
45–54 year old men and women in the most recent survey.
In contrast, less 55–64 and 65–74 year old men
reported moderate exercise and more of these men reported more vigorous exercise
than in the previous years. With the exception of 55–65 year old women,
there were trends of higher prevalences of previously diagnosed diabetes in the
most recent survey compared to the earlier years.
Table 5. Trends in cigarette smoking history and mean
(SE) number of cigarettes smoked in Auckland men and women by age group in 1982,
1986-8, 1993-4, and 2002-3
Table 6 also reports baseline values for absolute 5-year
cardiovascular disease risk (in %) by gender and age group, and the proportion
of participants with 5-year cardiovascular risk >15%. As expected, 5-year
cardiovascular risks were higher in men than women in the same age group, and
increased with age.
Table 6. Trends in leisure time physical activity (%)
and people with previously diagnosed diabetes mellitus (%) by age group in 1982,
1986-8, 1993-4, and 2002–3. Mean 5-year cardiovascular disease risk and
percentage of participants with 5-year cardiovascular risk >15% in
2002-3
1Question
not asked in the 1982 survey. 2Insufficient
information collected in previous surveys for calculation of 5-year
cardiovascular disease (CVD) risk with 95% confidence limits.
DiscussionThe most recent data from the
Diabetes, Heart and Health Survey indicate that the previously reported downward
trends in several major cardiovascular risk factors in Auckland since the early
1980s continues, however, the downwards trend in cigarette smoking appears to
halt between 1993–94 and 2002–3. There has also been a dramatic
increase in body mass index in both men and women with the prevalence of obesity
more than doubling over the 21-year period.
The major strengths of the current study are its size, and
its community-based sample. Limitations to the current study (and previous
studies) include the collection of a single measure of cholesterol, the
measurement of blood pressure on a single occasion, and that cigarette smoking
information was based on self-report. In addition, the falling response rates
over time are a cause for concern. However, it has been shown in the
Atherosclerosis Risk in Communities Study that differences between respondents
and non-respondents tended to exaggerate real differences between respondents
and the eligible population sampled.15
In general, non-responders were more likely to be current
smokers, and to self-report a lower prevalence of hypercholesterolaemia and to
self-report a higher prevalence of myocardial infarction, stroke, or
diabetes.15 Another limitation is that blood
pressure measurements were made in the morning in the 2002–2003 study
during an oral glucose tolerance test, whereas they were taken during the both
morning and afternoon in the previous studies under non-fasting conditions in
the pre-2000 surveys, factors that are known to affect blood pressure
levels.
Blood
pressure—Overall mean systolic and diastolic blood pressure levels
were lower in 2002–03 compared to those reported in the 1982 Auckland Risk
Factor Survey,4–6 1986-88 Auckland Heart
Study,5,6 and the 1993-94 Auckland Heart and
Health Study5,6 and showed a continued downward
trend of blood pressure levels in Aucklanders aged 35 to 74 years.
Blood pressure levels were also lower in all age groups than
the 1989 LINZ study,16 the 1988–90
Workforce Diabetes survey,17 the 1995–97
Workforce Diabetes Follow-up Survey,18 and the
1997 National Nutrition Survey.19
Furthermore, not only have systolic and diastolic blood
pressures decreased, but also the pulse pressure (systolic minus diastolic blood
pressure) has decreased over the studies. Pulse pressure is a marker of arterial
stiffness which increases with hypertension, ageing and diabetes, but is also an
independent marker of increased cardiovascular disease
events.20
The proportion of people with untreated blood pressure
levels >150/90 mmHg fell significantly by more than 83% (CI: 79%–87%)
in both men and women. This reduction was matched by an increase in the
proportion of people with blood pressure levels < 150/90 mmHg in both
genders.
When the age-standardised prevalences of raised blood
pressure among participants aged 36–64 years in the 2002–3 study
were compared to the 1982, 1986–88, and 1993–94 Auckland Heart
studies, there was strong evidence (p<0.0001) of a significant decline
according to treatment status over time in both men and women. However, current
cardiovascular disease guidelines10 recommend
that treatment should be based on absolute risk as shown in Table 6, where we
have presented baseline data for comparison with future studies, and not on
individual risk factors in isolation of the others.
Although blood pressure measurements obtained at a single
point in time may overestimate the prevalence of raised blood pressure, this
potential problem was minimised by taking two separate measurements and
averaging them, provided they were within 10 mmHg of each other, or taking
further measurements until they were.
It is unlikely that the use of different blood pressure
lowering instruments contributed to the falling blood pressure levels as the
instrument used in the 2002–3 survey was shown to measure approximately 2
mmHg higher for both systolic and diastolic blood pressure levels than the
random zero sphygmomanometer used in the previous studies.
Cholesterol—Previous
Auckland cardiovascular disease studies suggested that the population mean serum
cholesterol has decreased between 1982 and
1986–8.5 The 1997 National Nutrition
Survey reported a 0.2 mmol/L reduction in total serum cholesterol since the 1989
LINZ survey,19 with a mean cholesterol level of
5.7 mmol/L in European and Other men and 5.8 mmol/L in European and Other women
in the later survey. Prevalences of the use of lipid-lowering treatment and
hypercholesterolaemia were also higher in the current study compared to the
Workforce Diabetes Survey.18
It is possible that the different methods used to estimate
lipid levels have contributed to variation between the surveys. The
HDL-cholesterol method used in the last survey has been shown to estimate levels
0.1 mmol/L higher than for the HDL-cholesterol method used in the previous
surveys.9
Body mass
index—Because weight is an important determinant of serum
cholesterol18 and blood pressure
levels,21 the increase in body mass index in
the Auckland area over time would be expected to be accompanied by increasing
serum cholesterol and blood pressure levels. Surprisingly, however, systolic
blood pressure and serum cholesterol levels still appeared to be declining in
the current study, despite the unfavourable obesity trends.
Declining trends in fat and salt consumption and increasing
consumption of fruits, vegetables, and low-fat dairy products might account for
this anomaly, together with an increase in the number of younger people
reporting leisure-time physical activity (Table 6).
The proportion of participants who were overweight and obese
(70.9% of men and 57.0% of women) is higher than the 53.6% of men and 46.5% of
women reported in the 1997 National Nutrition
survey,19 thus confirming this upwards trend in
body sizes.
Body mass index reflects the balance of dietary intake and
energy expenditure. Increased body mass index influences other risk factors,
such as diabetes, raised blood pressure, and hypercholesterolaemia. Attributable
risk estimates, derived from the Framingham Study, showed that 78% of raised
blood pressure in men and 65% in women could be attributed to
obesity.22
Weight control programs could have a major impact on the
occurrence of raised blood pressure in young and middle-aged adults. Other
measures recommended to reduce the occurrence of raised blood pressure include
more exercise; avoidance of excessive alcohol intake; salt restriction; and
maintenance of normal calcium, potassium, and magnesium
intakes.22
Kannel et al have suggested targeting interventions towards
persons who are obese, have high normal blood pressure, or have a family history
of high blood pressure, as they have been shown in clinical trials using weight
reduction, exercise, and salt restriction to reduce the incidence of raised
blood pressure.22 Such measures have been
reported to reduce the prevalence of raised blood pressure in the population by
20% to 50%.22
Cigarette
smoking—The downwards trend in cigarette smoking observed between
1982 and 1993–94 appears to have ceased. These findings are consistent
with other recent New Zealand surveys23 and
indicate that it is time to reappraise current antismoking strategies. The most
effective public health strategies for reducing tobacco consumption are price
rises and legislation restricting where people can
smoke.23 Given the recent legislation to
prevent smoking in pubs and restaurants, further price rises should be
considered.
Leisure time physical
activity—The age-standardised prevalences for moderate leisure-time
physical activity were 25.8% in men and 21.4% of women in the 1982 survey, 34.6%
in men and 16.7% in women in the 1986-8 survey, 60.1% and 67.8% in women in the
1993-4 survey, and 66.0% in men and 71.9% in the 2002-3 survey, and appear to
have increased over the time period.
Similarly, the age-standardised prevalences of vigorous
leisure-time activity were 29.5% in men and 20.4% for women in the 1986–8
survey; 35.2% in men and 27.7% in women in the 1993–4 survey; and 32.8% in
men and 21.3% in women in the 2002–3 survey.
The 1996–7 New Zealand Health Survey reported that
overall 61% of adults were physically active.24
The 2003 New Zealand Health Survey reported age-standardised prevalence of
regular physical activity in Europeans and Others of 57.5% in men and 49.1% in
females, and that 79.2% of men and 70.6% of women were physically
active.25
Previously diagnosed
diabetes—The age-standardised prevalences of self-reported
previously diagnosed diabetes were 2.1% in men and 2.5% in women in the
1986–8 survey, 3.0% in men and 3.2% in women in the 1993–4 survey
and 4.5% in men and 4.8% in women in the 2003–4 survey.
The Workforce Diabetes Survey carried out between 1988 and
1990 reported a prevalence of 1.1% for previously diagnosed diabetes in
Europeans aged 40 years and over.26 A
door-to-door household survey carried out in 1992 in South Auckland reported an
age-standardised prevalence of 2.8% in Europeans aged 20 years and
over,27 and when the survey was extended
through to 1995, the same authors reported an age-standardised prevalence of
1.9% in Europeans.28
The 1996–7 New Zealand Health Survey of adults aged 15
year and over reported an age-standardised prevalence of 3.1% in
Europeans.24 More recently, the 2003 New
Zealand Health Survey reported age-standardised prevalences of self-reported
diabetes in Europeans and Others aged 15 years and over of approximately 3.5% in
men and 2.5 % in females.25
Low socioeconomic status is known to have an adverse affect
on many CVD risk factor levels.27,28 However,
this is unlikely to have influenced the results reported here, as all studies
had median socioeconomic status scores of 3 (on a 5-point scale).
In summary, the Diabetes, Heart and Health Survey found
favourable trends in systolic blood pressure, serum cholesterol, HDL-cholesterol
levels, and use of antihypertensive and cholesterol-lowering drug use in
Auckland between 1982 and 2002–04. However, there were unfavourable trends
in body mass index, obesity over the 21-year time period, and a recent levelling
of the previous decline in cigarette-smoking.
These findings suggest that the population burden of
cardiovascular disease may increase in the future unless renewed efforts are
made to tackle obesity and smoking, in particular.
Indeed, innovative and comprehensive programs targeted at
reducing cigarette consumption, increasing physical activity, and reducing
weight need to be implemented now.
Conflict of interest
statement: There are no potential conflicts of interest.
Author
information:
Patricia A Metcalf, Senior Lecturer and Senior Research Fellow; Robert KR
Scragg, Associate Professor; David Schaaf, Research Fellow – Division of
Pacific Health; Lorna Dyall, Senior Lecturer – Division of Māori
Health;
School of Population Health, Tamaki Campus Peter Black, Associate Professor
Department of Medicine, School of Medicine Rod Jackson, Professor, Division of Epidemiology and
Biostatistics
School of Population Health, Tamaki Campus University of Auckland, Auckland
Acknowledgements:
This survey was funded by the Health Research Council of New Zealand. We also
thank the technical and clerical staff who conducted the study so capably and
efficiently; the people of Auckland for participating; and North Shore and
Waitakere Hospitals, Te Pai Netball Centre, Takapuna District Cricket Club,
Belmont Rose Centre, Glen Eden Ceramco Park Centre, Nga Tapuwhai Community
Centre, Trust Health Care, Manuwera Nathan Homestead, Otara Leisure Centre (Te
Puke O Tara Community Centre), and the Mangere Town Centre for providing
examination rooms.
Correspondence: Dr
Patricia Metcalf, Division of Epidemiology and Biostatistics, School of
Population Health, Tamaki Campus, University of Auckland, Private Bag 92019,
Auckland. Fax: (09) 373 7018. Email: p.metcalf@auckland.ac.nz
References:
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