Cardiovascular disease (CVD) is one of the primary causes of death around the world, despite the widespread implementation of preventive strategies and the development of effective therapies [1
]. It was estimated that in 2013, approximately 17.3 million people died of CVD, with 80% of these deaths occurring in countries with a low or average income. On the contrary, in developed countries with high income, there was a noticeable decrease in the death rate caused by ischemic heart disease and cerebrovascular accidents [3
]. It is estimated that 4 million people die in Europe yearly due to CVD [5
]. Poland is classified as high-risk mortality country due to CVD (i.e., mortality of CVD >450/100,000 in men and >350/100,000 in women) [6
]. In addition, in Poland mortality due to CVD in rural areas is about 20% higher than in urban areas [7
Preventive measures implemented at the level of the general population, promoting a healthy lifestyle, as well as at the level of individual engagements, i.e., with those burdened with moderate to high CVD risk or patients with diagnosed CVD, play a significant role in preventing the development of cardiovascular diseases by modifying unhealthy style of life [6
]. The results of the Coronary Artery Risk Development In Adult (CARDIA) study suggest that 80% of CVS incidents can be avoided by optimizing the control of risk factors and adjusting the lifestyle, including changing the diet [9
]. The European Society of Cardiology (ESC), in the guidelines for the prevention of cardiovascular disease, emphasizes the need for lifestyle changes in the prevention of cardiovascular risk. The ESC sets goals aimed at modifying risk factors in clinical practice to which the patient should strive to minimize cardiovascular risk; these risk factors include: smoking (no exposure to smoke in any form), diet (low in saturated fat, containing whole grains, vegetables, fruit and fish), physical activity (≥150 min/week of moderate effort 30 min for 5 days per week or 75 min/week of vigorous physical activity or combination of the above), normal lipogram and blood glucose values, as well as body weight and perimeter belt (BMI 20–25 kg/m2
, waist circumference <94 cm, men or <80 cm in women). Moreover, the ESC recommends the use of cards Systemic Coronary Risk Estimation (SCORE) for the assessment of the overall cardiovascular risk in clinical practice [6
]. The ESC strategy for the prevention of cardiovascular disease focuses on reducing the risk factors.
In 2010, the American Heart Association (AHA) set itself the goal of improving cardiovascular health (CVH) by 20% in the American population by the year 2020. The concept of ideal cardiovascular health (ICH) was then created, the indicators of which allows to control and set strategic actions with respect to the practice of preventive cardiology. The defined criteria of ICH are based on the following 7-elements tool: four behavioral factors (smoking, physical activity, BMI, and diet) and three biological factors (blood pressure, blood glucose, and cholesterol levels). The level of maintaining particular components sets a CVH plane covering three categories: poor, intermediate, and ideal [4
]. This approach emphasizes primary prevention, in which effort is directed toward preventing the development of behavioral risk factors, which is the opposite of the secondary prevention, which focuses mainly on the occurrence or reoccurrence of CVD [10
]. Research has confirmed that the number of ideal factors of CVH is a strong indicator, one which is inversely proportional to mortality in American [11
] and Chinese populations [12
] and the changes in arterial vessels linked to atherosclerosis [13
]. Unfortunately, the occurrence of ICH remains low in the American and European population [14
]. Scientific publications regardingthe prevalence of ICH in Central-Eastern Europe are scarce, especially when it comes to those living in rural areas.
Poland was a developing country that underwent a political transformation, as did most countries in Central-Eastern Europe. Therefore, it is possible to assess the CVH for this part of Europe using Poland’s example. Research has shown that the risk of CVD is five times lower among people with ICH than that ofpeople with poor CVH [11
]. Therefore, identification of people with potentially modifiable barriers in reaching ideal CVH should be a priority for public health.
Therefore, in this study, we aimed to estimate the prevalence of ideal and poor CVH in the Polish adult population based on the example of inhabitants of the Janów district, in Lubelskie Voivodeship (Eastern Poland) following the criteria of the AHA. Our secondary objective was to assess the relationship between place of residence and gender and ICH.
Data of the Central Statistical Office, the Local Data Bank (GUS, BDL) for 2012 indicate that cardiovascular diseases were responsible for 58.1% of all deaths in Janów district, while in Poland in the analyzed period, mortality for the same reasons accounted for 46.1% of all deaths [19
]. Correspondingly, the analysis of many indicators of the socioeconomic situation of people living in this area was also very unfavorable, similarly when compared to the general population, i.e., a higher rate of people with primary education in relation to the general population (27.55% vs. 23.2%, respectively) [20
], and an unemployment rate of 15.6%, compared with an unemployment rate of 14% for the country [21
]. The indicator regarding the number of people in families who receive social assistance for Janów district was relatively high—the social welfare system covered as much as 14.6% of the population (for comparison, the average in Lubelskie Voivodeship is 9.4%) [22
In this study, we aimed to estimate the prevalence of the seven CVH metrics—four behavioral and three biological—and we also estimated the accumulated CVH indicators according to the criteria recommended by the AHA using a cross-sectional analysis of data obtained from 3901 people aged between 35 and 64 years from the Janów district in Eastern Poland. We also studied whether the place of residence (urban or rural areas) and gender determines the level achieved with respect to ICH. Our study showed that the place of residence is significantly related to the ideal global ICH. Respondents living in rural areas had a lower chance of having the ICH according to the AHA criteria.
In Poland, two major studies on representative samples have been carried out, evaluating the prevalence of risk factors for cardiovascular diseases. These were WOBASZ, a multicenter nationwide study of the Polish population’s health and Polish part of the project HAPIEE (Health, Alcohol and Psychosocial Factors In Eastern Europe). The WOBASZ study was conducted among a representative sample of the general population, whereas the HAPIEE study included a representative sample for the city of Cracow [28
]. In our study, we had a lower percentage of smokers and a lower percentage of participants with hypercholesterolemia among men and women than in the HAPPIE and WOBASZ studies. Also, women we examined had lower blood pressure values than in the HAPIEE and WOBASZ studies, while men were characterized by lower blood pressure values than men tested in the HAPPIE project, but higher than in the national sample. Among the surveyed women and men living in Janów district, the percentage of obese people was higher than in the studied population of Cracow and general one [8
]. It should be noted, however, that our study was conducted about 10 years later and in broader age groups. Therefore, it is not surprising that the frequency of ICH in terms of 5–7 factors in the researched Polish population was found to be very low, and pertained to only 5.4% of the people. Of those researched, only 0.1% achieved 7 components of ICH metrics, which is considered to be minor. Similar results were found by Manczuk et al. [30
]. However, in their research, performed on 10,687 people in Kielce, South-Eastern Poland, none of the respondents reached all seven ideal ICH components.
The frequency of occurrence of all seven CVH indicators is low all over the world, and varies from 0.2% to 15%, depending on geographical location, age, gender, ethnic background, and education level [16
]. The rate of achieving ICH results (5–7 ideal metrics) in the researched Polish population was higher than in the Iranian population [35
], in the adult population of Republic of Serbia, as well as the adult population of Bosnia and Herzegovina [10
]. However, their results were lower than the results of those from Brazil [36
], the Canadian research conducted by Maclagan et al. [37
], the research of the population of Peru [34
], and samples of the American population [38
Understanding the potential of cardiovascular health in the adult population in terms of society was implemented by investigating 7 significant factors: four behavioral components and three biological components, enabling improved planning concerning the health policy by creating local conditions and developing health programs tailored to the needs of the community to which it is addressed.
This study suggests that the percentage of people with ICH living in rural areas was significantly lower than in those living in the urban areas (5.0% vs. 6.3%). Moreover, living in rural areas was linked to a lower chance of reaching an ideal BMI, having an ideal diet, and ideal arterial blood pressure. However, it was more likely for those residing in rural areas to be non-smokers than residents of urban areas.
Observed imbalances in CVH are undoubtedly correlated with a higher number of males living in rural areas, as well as a lower rate of people with higher education living in rural areas, which might cause the guidelines concerning a healthy lifestyle to be ignored. Living in rural areas may also be connected to a limited access to health services. In a study conducted in Peru, the average number of ICH components in the rural area of Tumbes was found to be 2.82, which was significantly lower compared to the residents of the city of Lima [34
].Socioeconomic inequalities in overall mortality in a prospective population study (in the group of 16,812 men and 19,180 women aged 45–69) in the Czech Republic, Russia, Poland and Lithuania evidently support the results of the HAPIEE study. The results emphasize the importance of all the tested socioeconomic position (SEP) elements, significant for understanding mortality inequality in the countries of Central and Eastern Europe [40
]. In accordance with the existing research [17
], we observed that women were more likely to have ICH compared to men. Studies including this suggest that there should be additional effort put into the promotion of primary prevention of CVD [15
Among the behavioral components of ICH metrics, the best factor assisting the achievement of ICH was not smoking (63.1% of the researched), and the most difficult with regard to maintaining CVH was practicing an ideal healthy diet, which was only achieved by 6.5% of respondents. These results have been confirmed by the systematic review conducted by Younus et al. [32
], where the prevalence of the ideal classification of non-smokers in the analyzed population was higher, and the poorest indicator was the diet. The above observation of such a low maintenance index of Ideal Healthy Diet in conducted research, as well as other authors, is a particularly important issue considering the HAPIEE study. The findings from the HAPIEE study confirm the hypothesis that an unhealthy diet play an important role in high mortality due to CVD in countries in Central and Eastern Europe (CEE) and the Former Soviet Union (FSU) [44
]. Of all the biological components of ICH metrics, only 10.3% in the researched group had ideal blood pressure, out of which a greater percentage were living in the urban areas rather than in rural areas.
The idea of strengthening CVH should be applied to the health policy of the country, especially via the prism of primary prevention aimed at the weakest links of the society, namely people with a lower education, those living in rural areas, and males. Our discovery could have a potential impact on individual and public health. Intensified efforts aimed at taking behavioral factors (especially diet and body mass) into consideration are necessary, as well as the detection and control of biological factors, especially measuring of arterial blood pressure. The relation between ICH and residing in urban areas versus rural areas has been shown. Efforts aimed at the promotion of CVH and prevention of CVDs should especially focus on residents of rural areas.
6. Study Limitations
Our research has certain limitations which should be considered. First, this study was concerned with the population of South-Eastern Poland, in addition, the selection of participants was devoid of randomization and stratification concerning the sample with respect to their age and gender; also, the data on cardiovascular events and heart disease of the participants (which were the exclusion criteria) were collected on the basis of direct interview, without examining the medical history of the patient. Future studies should be conducted on a representative sample for Polish population. In addition, the cross-sectional design of the presented study and the analysis of results reduces its strength for cause-and-effect reasoning, showing only a tendency of the relationship between biological and behavioral factors and CVD.
Another limitation is the questionnaire assessing physical activity and diet. In terms of physical activity, the participants were asked only one question, and because of this, there was no middle category in ICH. The diet questionnaire did not include a question concerning fish and seafood consumption, which generally results from the low popularity of fish and seafood among the Polish population, as well as the high price of these products, which are rarely eaten by the less affluent rural areas residents. In Poland, people consume a lot of potatoes, pork, butter, cereal preparations, vegetables, sugar, and small amounts of fruit, veal, beef, milk, and fish [45
]. Therefore, our diet questionnaire was customized to the dietary trends in Poland. However, neither ESC, nor AHA explicitly recommend a questionnaire for the assessment of diet; therefore, we used a questionnaire which contains a large part of questions in accordance with the ESC and AHA dietary guidelines, which indicate the dietary patterns desirable from the perspective of prevention of cardiovascular risk.
Our analysis concerning the prevalence of ICH consisted of the qualification of 5–7 factors as a measurement of ICH. Many available studies qualify 6–7 factors as the ICH measurement according to the AHA criteria [15
]. Observed differences in the qualification approach demand standardization for a better understanding of the real determinants of ICH. It also needs to be observed that the creation of ICH results is-based upon the usage of binary variables, with the assumption that all health behaviors and factors affect the final result.
Our research proved that important trends in health behaviors and biological factors were linked to the maintenance of CVH in Poland within the adult population, as exemplified by the population of Janów disctict, in Lubelskie Voivodeship. Although the levels of physical activity, nonsmoking, or healthy diet can be improved, the problems of obesity, hypertension, and diabetes worsen, which demands greater attention. Based on the visible positive changes of certain health behaviors, what is needed is targeted political and program intervention to increase all factors. This includes physical activity and diet quality, which shall prospectively improve the state of CVH in the Polish people, and the frequency of occurrence of CVD shall decrease.
We expect that the CVH index will be a useful tool for the whole of society, clinicians, researchers, as well as the policymakers interested in the monitoring of CVH, in order to decrease the level of the social burden caused by CVDs in Poland.