Hrev_master [Healthcare in Low-resource Settings 2018; 6:6468] [page 11] Healthcare in Low-resource Settings 2018; volume 6:6468 Increased waist circumference as an independent predictor of hypercholesterolemia in community-dwelling older people Claudineia Matos de Araujo,1-3 Marcos Henrique Fernandes,1,2 José Ailton Oliveira Carneiro,1,2 Raildo da Silva Coqueiro,2 Rafael Pereira1-3 1Postgraduate Program in Nursing & Health; 2Center for Studies in Aging Epidemiology (NEPE); 3Research Group in Neuromuscular Physiology, Department of Biological Sciences, State University of Southwest Bahia (UESB), Jequié, Brazil Abstract Hypercholesterolemia is a worldwide public health problem, contributing to cere- brovascular and ischemic heart diseases as one of the major cardiovascular risk factors, and associated with approximately 4.4 mil- lion deaths each year worldwide. This study aimed to evaluate the association and pre- dictive value of increased waist circumfer- ence (WC) to identify hypercholesterolemia in community-dwelling elderly people. In a cross-sectional, home-based epidemiologi- cal survey, 296 community-dwelling old adults consented to capillary blood collec- tion and anthropometric evaluation. Total cholesterol was quantified, and the popula- tion was stratified as normal or high (≥200 mg/dL). WC was used to stratify the popu- lation into normal or elevated values (men: ≥90 cm; women: ≥80 cm). The association was investigated using logistic regression. Increased WC was associated with a greater probability of hypercholesterolemia (OR=2.82, 95%CI 1.68 to 4.74). Thus, the widely used WC cutoff was demonstrated to be significantly associated with hypercho- lesterolemia in community-dwelling elderly people and could serve as a useful screening tool for hypercholesterolemia in older adults. Introduction Elevated total cholesterol (i.e., hyperc- holesterolemia) is a worldwide public health problem contributing to cerebrovas- cular and ischemic heart diseases.1 In Brazil, as well as in other developing coun- tries, cardiovascular diseases account for one third of all deaths and are the main source of healthcare expenditure. The hypercholesterolemia is one of the major cardiovascular risk factors and estimatives have associated hypercholesterolemia with approximately 4.4 million deaths each year worldwide.2 Additionally, it is estimated that, in 2025, the number of deaths/year attributed to hypercholesterolemia will increase to 25 million.3 It is known that the aging enhances the probability to develop cardiovascular and metabolic complications, including hyperc- holesterolemia.4 Notwithstanding, the body composition changes associated to aging process lead to an increased fat deposition with consequent cardiovascular and meta- bolic disorders, including insulin resistance, hyperlipidemia, hypertension, coronary artery disease.5 In this context, Rezende et al. (2006) observed that, in adults and older people, the abdominal or central obesity is correlat- ed with many cardiovascular risk factors, including the hypercholesterolemia. The excessive body fat may be identified by anthropometric measurements, including body mass index (BMI), an indicator of overall obesity, and waist circumference (WC), an indicator of central or visceral obesity.6-8 Anthropometric measurements are easy-to-apply and low-cost when compared to more precise methods for body composi- tion assessing, allowing its use in popula- tion-based studies to assess changes in body composition, as well as in clinical situations where access to technology is limited,5 which is especially important to developing countries. Thus, they should be used in household surveys, epidemiological popu- lation-based studies, clinical practice and primary health care in many scenarios.9 Although LDL cholesterol, total choles- terol/HDL ratio, and specific apolipopro- teins can be better cardiovascular risk indi- cators, the analysis of total cholesterol alone is suitable for population studies, since the analysis of serum lipoproteins and apolipoproteins are not available for all population in many countries.2 Thus, this study aimed to evaluate the association and predictor value of increased waist circum- ference to identify hypercholesterolemia in community-dwelling older people. Materials and Methods This is a descriptive study with cross- sectional design, which analyzed data from a home-based epidemiological survey called “Nutritional status, risk behaviors and health conditions of older people from Lafaiete Coutinho, Bahia.” The study was developed in Lafaiete Coutinho, Bahia, which had, registered in the Family Health Strategy (FHS), 3,901 inhabitants the urban area at the collection period.10 The study population consisted of all individuals aged ≥ 60 years, of both sex, not institutionalized and residing in the urban area and registered in the FHS. From all res- idents in urban areas and aged ≥ 60 years (n = 355), 316 (89.0% participated in the sur- vey, it were registered 17 refusals (4.8%) and 22 (6.2%) subjects were not located after three home visits in different days, then, it were considered as losses. The research procedures were approved by the local Ethics Committee (No 064/2010). Participation was voluntary, and individuals signed and informed consent, according to the ethical standards required by Resolution No 196/96 of the National Health Council. Correspondence: Rafael Pereira, Department of Biological Sciences, State University of Southwest Bahia, Rua José Moreira Sobrinho s/n, Jequiezinho, Jequie 45210-506, BA, Brazil. E-mail: rafaelpereira@uesb.edu.br Key words: anthropometry; aging; choles- terol. Acknowledgements: the authors thank the Municipal Secretariat of Health of Lafaiete Coutinho-BA and the elderly who participated in the study. Contributions: CMA, MHF, RSC, JAOC, data collecting and analyzing; CMA, RSC, JAOC, manuscript writing; MHF, funds collection; RP, MHF guiding overall work of the research. Conflict of interest: the authors declare no potential conflict of interest. Funding: this work was supported by the State University of Southwest Bahia (UESB) (Grant numbers UESB 117/2009 and 011/2010) and Foundation for Research Support of the State of Bahia (FAPESB) (Grant number PPP0070/2011). Received for publication: 13 December 2016. Revision received: 23 June 2018, Accepted for publication: 25 June 2018. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright C.M. de Araujoet al., 2018 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2018; 6:6468 doi:10.4081/hls.2018.6468 No n- co mm er cia l u se on ly Data collection The data were collected in January 2011 by the interviewers with the support of community workers in each area of the FHS. Data were collected in two stages: the first stage consisted of home interviews with a previously validated questionnaire,11 which involved socio-demographic, lifestyle and cognitive evaluation. The sec- ond stage involved blood sampling, car- diorespiratory tests, anthropometric meas- urements and motor performance tests. Total cholesterol and hypercholes- terolemia (dependent variable) After 12 hours of fasting the total cho- lesterol (TC) was quantified from capillary blood samples with the Accutrend Plus® system (Roche Diagnostics, Germany), a previously validated analyzer.12 After 5 minutes of rest in a sitting position, capil- lary blood samples were collected through transcutaneous puncture on the medial side of the middle finger tip using a disposable hypodermic lancet. The study population was stratified into normal or Hypercholesterolemia according the recom- mended values (TC ≥ 200 mg/dL) in the VI Brazilian Guidelines on Hypertension13 and V Brazilian Guidelines on Dyslipidemia and Prevention of Atherosclerosis.14 Increased waist circumference (pre- dictor variable) The measurement of waist circumfer- ence (WC) was obtained with inelastic tape (graduated in centimeters), positioned over the umbilicus, with the patient standing. The International Diabetes Federation (IDF) in 2005 proposed a cutoff point for WC that differs between ethnic groups, being used in this study the cutoff ≥ 90 cm for men and ≥ 80 cm for women, as recom- mended by IDF for the ethnic group from Central and South Americans.15 Statistical procedure Descriptive analysis was conducted with frequencies, means and standard devi- ations of the population characteristics. Initially, the chi-square test was applied to verify the association between waist cir- cumference and the dependent variable hypercholesterolemia, which was con- firmed (p <0.001). Thus, the data were sub- mitted to logistic regression analysis to ver- ify the association strength between vari- ables. From the logistic regression parame- ters, the odd ratio was calculated with respective 95% confidence intervals (95% CI). Data were analyzed in SPSS Statistics software for Windows (SPSS 21.0, 2012, Armonk, NY: IBM Corp.) and the signifi- cance level was 5% (α = 0.05). Results From the 316 older people included in the study, 296 (74.2 ± 9.7 [60 to 105] years old) had total cholesterol and WC data col- lected. In this population, the prevalence of hypercholesterolemia was 51.4% (152 sub- jects), which was higher in women (106 women, corresponding to 69.7% of all cases of hypercholesterolemia). Two hundred and seven (69.9%) subjects presented WC above to the used cutoff values (≥ 90 cm for men and ≥ 80 cm for women), of whom 144 (69.6%) were women. The results from the logistic regression showed a strong association between WC (categorized) and hypercholesterolemia (p < 0.001). Table 1 shows the results of logis- tic regression, allowing to verify that a waist circumference measure above the established cutoff values (≥ 90 cm for men and ≥ 80 cm for women, respectively) impacts in greater chance of presenting hypercholesterolemia (OR = 2.82, 95% CI 1.68 to 4.74). Discussion This study aimed to investigate the association strength of WC and hypercho- lesterolemia in community-dwelling older people. The results showed that the increased WC was strongly associated to hypercholesterolemia in the studied popula- tion. The aging process is associated to sig- nificant changes fat, muscle and bone mass, with an increase of fat mass and decrease in muscle and bone mass. The accumulation of intra-abdominal fat (i.e., visceral fat) is a major risk factor for several diseases, and have attracted special attention when com- pared to other forms of body fat distribu- tion,16 which is justified by the fact that vis- ceral fat have different metabolic character- istics of subcutaneous fat that favor the installation of metabolic alterations that cul- minate in increased cardiovascular risk.17,18 The WC measurement does not allow inferring directly the amount of visceral fat, distinguishing from the subcutaneous fat in the abdominal section. However, Ross (2003),19 suggest that subcutaneous and vis- ceral fat are highly correlated in the abdom- inal section. Additionally, Ribeiro Filho et al. (2006)18 and Rothberg et al. (2015),17 highlight that, among the available anthro- pometric methods to analyze the central dis- tribution of body fat, the WC is the most widely used method for assessing visceral adiposity, because it is easy to collect and involves a single measure, being less sub- ject to the measurement variability. Zahorska-Markiewicz (2006)20 states that the WC is the best predictor to the development of cardiometabolic diseases. Rezende et al. (2006),6 studying a popula- tion with a wide age range (21-76 years) reported that the WC, as stratified here, is better associated to cardiometabolic risk factors, than the body mass index. Our results corroborate Zahorska-Markiewicz (2006)20 and Rezende et al. (2006),6 and strengthen the understanding that the asso- ciation between WC and hypercholes- terolemia, an important cardiometabolic risk factor, is applies to the older people, since we found a greater association between hypercholesterolemia and increased WC (OR = 2.82, 95% CI 1.68 to 4.74) in older people, independently of sex. Nevertheless, Nagatsuyu et al. (2009)21 did not identify a significant association between waist circumference (measured at the umbilicus) and total cholesterol values. The form of analysis of the variable as con- tinuous data, besides the fact that the cited study involved a smaller number of elderly people (only 98 older people), can justify the divergence from our results. It is noteworthy that the accumulation of visceral fat also indicates a greater reserve of nutrients in the lipids form, so that the establishment of a cause-effect rela- tionship between hypercholesterolemia and the visceral fat accumulation, as measured by WC, is complex. Our finds should encourage the use of anthropometric indica- tors of easy application and interpretation for clinical purposes and epidemiological research in order to prevent, maintain or improve monitoring of blood total choles- terol in the elderly of both sexes. Article Table 1. Regression coefficient, Odds Ratio (OR) with its 95% confidence interval (CI) obtained in the logistic regression. Lafaiete Coutinho, Bahia, Brazil, in 2011. Variable RC Standard Error of RC OR 95% CI of OR Waist Circumference 1.038 0.265 2.82 1.68 - 4.74 Constant -0.6763 0.224 - - RC, regression coefficient. [page 12] [Healthcare in Low-resource Settings 2018; 6:6468] No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2018; 6:6468] [page 13] Conclusions The results of this study showed that the WC is significantly associated to hypercho- lesterolemia in the older population, sug- gesting that the WC measure, categorized in ≥ 90 cm for men and ≥ 80 cm for women, could be used as a tool for health surveil- lance when the goal is to identify older peo- ple more prone to hypercholesterolemia. References 1. NCEP Expert Panel. Third Report of National Cholesterol Education Program (NCER) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Final Report. Circulation 2002;106:3143–421. 2. Farzadfar F, Finucane MM, Danaei G, et al. 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