Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: July 28^th 2015

Accepted: February 18^th 2016

Prevalence of cardiovascular risk factors in a population of health-care workers

Claudia Nelly Orozco-González,^a Laura Cortés-Sanabria,^a Juan José Viera-Franco,^b José Juan Ramírez-Márquez,^b Alfonso M. Cueto-Manzano^a

^aUnidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades

^bDepartamento de Fomento a la Salud, Hospital de Gineco-Obstetricia

Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Jalisco, México

Communication with: Laura Cortés-Sanabria

Telephone: (3) 668 3000, extensión 32204

Email: cortes_sanabria@yahoo.com.mx

Background: To determine the prevalence of cardiovascular risk factors (CVRF) in healthcare workers from two tertiary-care hospitals of the Mexican Institute of Social Security, as well as their association with professional activities (PA).

Methods: Descriptive study. One-thousand eighty-nine health-care workers ≥ 18 years were included. Clinical history, physical exam, and blood tests were performed.

Results: Mean age 41 ± 9 years, 76% women. Hypertension prevalence was 19%, diabetes mellitus 9.6%, dyslipidemia 78%, overweight and obesity 73%, metabolic syndrome (MS) 32.5%, and smoking 19%. The following significant associations (p < 0.05) were found: MS with medical asisstants (OR: 2.73, CI 95%: 1.31-5.69) and nutritionist (OR: 2.6, CI 95%: 1.31-5.24); obesity with administrative personnel (OR: 3.64, CI 95%: 1.40-7.46); dyslipidemia with medical asisstants (OR: 2.58, CI 95%: 1.15-6.34). In the whole sample, the probability to have a vascular event in the following 10 years was 10%.

Conclusion: Prevalence of CVRF was high in this sample of health-care workers and did not seem to be different from those in general population. Medical assistants, nutritionist, and administrative personnel displayed a higher risk. It is necessary to create programs to promote healthy lifestyle and to improve the epidemiological profile of health-care workers.

Keywords: Cardiovascular risk factors; Health-care workers; Prevalence

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Despite great progress made to reduce morbidity and mortality from cardiovascular disease (CVD), it remains a major global health problem, which is exacerbated in developing nations.¹ CVD has become the leading cause of death, and epidemiological analysis of this phenomenon has allowed us to recognize a number of factors that determine an increased risk of cardiovascular morbidity and mortality.² In Mexico, the Encuesta Nacional de Salud y Nutrición 2012 (ENSANUT, 2012)³ reports a high prevalence of obesity, diabetes, hypertension, and dyslipidemia; these cardiovascular risk factors (CRFs) potentiate each other and frequently occur in association; however, most of them are also modifiable or manageable. Advances in the prevention of cardiovascular death in the last two decades have been relevant to identify and use the stratification of risk factors to estimate the 10-year risk of CVD.⁴ Therefore, early identification of CRF is a preliminary and often forgotten step to prevent the development of CVD. However, the staff working in health institutions could differ because health practice leads to a consistent and reiterated familiarity with the illness and death of others. This may lead health workers to be aware of the vulnerability of human beings and themselves;⁵ this vulnerability is a persistent reminder of an increased risk of morbidity and mortality. However, there are few studies that address both aspects of self-care for health professionals and the distribution of cardiovascular risk factors. Therefore, the objective of this study was to determine the prevalence of cardiovascular risk factors in workers at high specialty hospitals of the Instituto Mexicano del Seguro Social (IMSS), and to identify the association between work and these risk factors. 

Methods

This descriptive study was conducted in two highly specialized hospitals (Hospital de Especialidades and de Gineco-Obstetricia of Centro Médico Nacional de Occidente), at IMSS in Guadalajara, Jalisco, Mexico; the workers included were ≥ 18 years old, of either sex, any category and time of service. Subjects with secondary causes of hypertension were excluded, or those receiving medications for some other pathology which themselves raise the levels of blood pressure, glucose, or lipid profile, as well as pregnant women.

The sample selection was done by non-probability "consecutive case" sampling (including only those workers who attended the clinical checkup at the health promotion department for workers in each hospital, and who agreed to participate in the study). The sample size was sufficient to detect conditions with a prevalence of hypertension (HT) (considered one of the most prevalent CRFs in the Mexican population) of at least 30%, with a confidence level of 95% and a sample power of 80%. The CRFs assessed were overweight and obesity, smoking, dyslipidemia, hypertension, diabetes mellitus type 2 (DM2), and metabolic syndrome (MS). 

Workers of both hospitals got a medical history and physical examination in an initial interview. Blood pressure (BP) was taken with the subject seated comfortably, with 15 minutes of rest, provided they had not consumed alcohol, coffee, or tobacco 30 minutes before measurement. BP was measured on 3 separate occasions with intervals of 3 minutes each, and the average of all was considered. Criteria from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure⁶ were used for the decision and classification of BP. Body mass index (BMI) was calculated based on the Quetelet index (weight [kg]/height2 [m2]).⁷ Venous blood samples were obtained from all workers to determine glucose, total cholesterol (TC), low-density cholesterol (LDL-C), high density cholesterol (HDL-C), and triglycerides, using the method of dry chemistry.

Definitions

The diagnosis of type 2 diabetes or impaired fasting glucose was done according to the criteria of the American Diabetes Association.⁸ Diagnosis and classification of HT was done according to the criteria of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.⁶ MS and lipid profile disorders were defined based on the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III).⁹ Overweight and obesity were defined according to the criteria of the World Health Organization (WHO).¹⁰ The probability of coronary heart disease (stable angina, unstable angina, AMI, and coronary death) in a period of 10 years was calculated using the Framingham risk tables by category.¹¹ The coronary heart disease score is obtained using the categories: CT or C-LDL, age, HDL-cholesterol, high blood pressure, diabetes, and smoking. The estimated risk for coronary heart disease over a period of 10 years is based on the Framingham experience in men and women aged 30 to 74 years old. Smoking was defined if patients had smoked > 100 cigarettes in their lifetime and still smoked at the time of the study.¹²

Statistical analysis

In the case of quantitative variables, data are shown as mean ± standard deviation (SD) or median (percentiles 25-75%), depending on if the distribution was parametric or non-parametric, respectively. Qualitative variables are expressed as numbers or percentages. The prevalence of CRF was established. Comparisons between groups were established by Chi-squared in the case of nominal or categorical variables. Multivariate analysis was done using logistic regression to identify cardiovascular risk factors associated with the type of work activity. A p-value < 0.05 was considered significant. SPSS for Windows, version 19.0 was used for data analysis. 

Results

1089 workers were studied, the average age was 41 ± 9 years (46% of the population had an age range between 41 and 50 years), 827 were women (76%). By labor activity, 51% (n = 552) were in the ​​nursing area; 20% (n = 213) in the administrative area; 7% (n = 64) in the medical area; 5% (n = 59) in the nutrition/dietician area; 4% management; 3% laboratory, and 10% other areas.

Prevalence of cardiovascular risk factors

The prevalence of cardiovascular risk factors in health workers is shown in Figure 1. The prevalence of hypertension in the total sample was 19% (95% CI 16.7-21.6%). In 34% of hypertensive workers, the diagnosis was established at the time of the study. The average systolic blood pressure (SBP) was significantly higher in patients with newly diagnosed hypertension compared to those already known to be hypertensive (140 ± 10 mmHg versus 130 ± 14 mmHg, p < 0.0001). The average diastolic blood pressure (DBP) in known hypertensives was 81 ± 10 mmHg, while for workers with newly diagnosed hypertension it was 91 ± 9 mmHg (p < 0.0001).  

The prevalence of DM2 in the total sample was 9.6% (95% CI 8.0-11.5%). Sixty-one percent of diabetic workers were between 41-50 years of age. In 33% the diagnosis was established at the time of the study, and their average glucose was 138 ± 5 mg/dL. The proportion of diabetic workers with fasting glucose ≤ 100 mg/dL was 55%. The prevalence of impaired fasting glucose was 20%. 

The prevalence of dyslipidemia in the entire sample was 78% (95% CI: 76-80.7%). Total cholesterol was high in 37% of workers, LDL-C in 54%, triglycerides in 44%, and an HDL level below recommended in 48% of women and 16% of men, respectively.

Overweight and obesity affected 73% of workers (95% CI: 70.2-75.8%). The prevalence of obesity was 32% (obesity grade I 22%, grade II 7%, grade III 3%). The average BMI in the whole sample of workers was 28 ± 5.2.3 kg/m2, and in the group with obesity 34 ± 4.3.3 Kg/m2. The prevalence of waist circumference defined as high cardiovascular risk was 47% in women and 34% in men (p < 0.0001). The prevalence of MS was 32.5% (95% CI 29.8-35.3%). In workers with MS, 68% had 3 criteria, 24% had 4 criteria, and 8% had 5 criteria. Smoking prevalence was 19% (95% CI 16.5-21.5%) across the sample of health workers. According to the co-occurrence of CRF, 660 workers (61%) had ≥ 3 cardiovascular risk factors.    

Distribution of cardiovascular risk factors by sex

Figure 2 shows the distribution CRF by sex. The prevalence of dyslipidemia, hypertension, metabolic syndrome, overweight, obesity, and smoking was significantly higher in men than in women. The prevalence of DM by sex was no different between men and women. The co-occurrence of cardiovascular risk factors was significantly higher in men (68.7%) than in women (58%) (p = 0.012).

Cardiovascular risk factors and type of work activity

When comparing the prevalence of cardiovascular risk factors by type of work activity, only obesity, dyslipidemia, metabolic syndrome, and smoking were significantly different between work areas (Table I). The presence of ≥ 3 CRFs was more frequent in the areas of nutrition-dieticians and medical assistants (nutrition 74.6%, medical assistants 70.8%), followed by the nursing area (63.4%), administration (62.4%), and medical (48.4%), while the area with the least frequency was laboratory workers (42.9%); all of these differences were statistically significant (p = 0.003). 

In association analysis, the CRFs that were significantly associated with the type of work of health workers were: metabolic syndrome, obesity, and dyslipidemia (Table II). The areas of nursing, administration, food handlers, and medical assistants were significantly associated with the prevalence of MS, while the areas of nursing, administration, and medical assistants were associated with obesity; the areas of nutrition/dieticians, administration, and medical assistants were associated with dyslipidemia. No association was found between the type of work activity and smoking, hypertension, diabetes, and obesity.

Cardiovascular risk according to the Framingham index

Additionally, an analysis was performed to determine the probability of developing CVD in 10 years, according to the number of risk factors present. 90% of workers had less than 10% probability of 10-year CVD risk, 7% between 10-15%, 2% between 16-20%, and 1% had a risk over 20% (Figure 3).

Discussion

The present study has demonstrated for the first time the distribution of cardiovascular risk factors among workers in the most important public institution in Mexico, the Instituto Mexicano del Seguro Social, the entity responsible for granting social security to more than half of the Mexican population. Contrary to expectations, our results are consistent with the prevalence of cardiovascular risk factors reported in the last two national health surveys conducted in the general population.^3,12 Taken together, these results highlight the responsibility of public and private social security institutions to strengthen their role in health promotion and health prevention, not only for their employees but also for their affiliate companies.¹³ The above results have reinforced our view about the epidemiological profile of workers’ health: despite themselves belonging to the service sector, whose essence lies in care for others, their profile is no different than that of the general population.^3,12 This is surely because in the end the workers, as members of society, are involved in psychological, sociocultural, and economic phenomena that are difficult to change, even for a work environment related to the ​​health sector.¹⁴

Moreover, within the medical model in which these professionals have been trained, healing is privileged, and some authors even say that prevention is secondary to it. Consequently, the cultural capital of health professionals acquired through their training and their professional practice focuses primarily on healing, while promoting prevention has a secondary importance. In fact, there is an overestimation of such knowledge, which leads to an attitude of disdain especially in regards to different actions for health care.¹⁴

HT is one of the most important risk factors for developing cardiovascular disease, stroke, and kidney failure, which are other major causes of death in Mexico.¹⁵ Between 2006 and 2012, the prevalence of HT remained so high that it affected just over 30% of Mexican adults.^3,12 These results differ from those found in our study, where the prevalence of HT was much lower (19%). However, one of the important issues arising from this study is that for 34% of hypertensive workers, the diagnosis was established at the time of the study. Although early diagnosis has increased in the case of diseases such as diabetes, the proportion of individuals with early diagnosis of hypertension has not presented the same trend in the last six years (although this is simpler and non-invasive). Improving this diagnosis would be very important to facilitate the goal of timely control through lifestyle measures.¹⁶

In recent decades, the number of people with diabetes in Mexico has increased, and it is now the second leading cause of death in the country. Of the total adult population in Mexico, 9.17% (95% CI: 8.79-9.54%) report having a previous diagnosis of diabetes by a physician.¹⁷ These results are no different from those reported in our study (9.6% prevalence). The finding of 20% of impaired fasting glucose has important implications, considering these health workers as a group at high risk for diabetes and cardiovascular disease.  

In Mexico, a slight decrease is observed between 2000 and 2012 in the total percentage of adults who reported using tobacco (22.3-19.9%, a statistically significant difference).3,12 In the present study, the percentage of all workers who consume tobacco was the same as reported by ENSANUT in 2012 (19%).

Unfortunately, more than half of the workers presented the co-occurrence of ≥ 3 risk factors, which is of extraordinary importance because of the negative impact that the sum of these cardiovascular risk factors could have on cardiovascular morbidity and mortality (isolated HT is responsible for 13% of deaths worldwide, tobacco use [9%], elevated glucose [6%], physical inactivity [6%], and overweight and obesity [5%]).¹⁸

The total proportion of physicians in this study was very low (7%). These results agree with those obtained by Arenas et al.,¹⁴ who found that doctors postpone their medical checkups with healthcare professionals when they have specific symptoms, because they know in advance both the procedures that they will be subjected to, and the possible results. In addition to the professional habitus, there are also the characteristics inherent to health institutions that mark the rhythms and movements of the health profession. Mainly, doctors, losing control over the pace of work, have diminished autonomy and serious limitations when taking care of their health. Moreover, most health workers have multiple jobs, making them accumulate working schedules ≥ 100 hours per week. This problem has a decisive influence on self-care provided, hindering activities of sleep, rest, and recreation, among others, which has the main impact of stress overload, loss of healthy eating habits, increased blood pressure, and therefore heart problems.¹⁹

There is limited evidence to support the distribution of cardiovascular risk factors and/or chronic degenerative diseases in health workers by sex and/or work activity, not only in our country but also internationally, so it is difficult to explain our results. The significant increase in the prevalence of cardiovascular risk factors in men such as dyslipidemia, HT, MS, overweight-obesity, and smoking is difficult to explain, especially since the percentage of people who received preventative medical care by type of service in Mexico was no different between men and women.3 However, a possible explanation for these findings is that it may be related to the likelihood of better control of CRFs in females due to greater use of curative services and ambulatory primary care for women.²⁰

The Pan American Health Organization (PAHO) considers the workplace a priority for health promotion in the twenty-first century environment. A healthy working environment is essential not only to ensure the health of workers, but also to make a positive contribution to productivity, work motivation, the spirit of work, job satisfaction, and overall quality of life.13 There is strong scientific evidence that addressing diet and physical activity in the workplace opens up the possibility of improving workers’ health; contributes to a positive social image of the company; increases staff morale; reduces staff turnover and absenteeism; increases productivity; and reduces sick leave, lowers costs of health care, and reduces the quotas of accident and disability insurance for workers.^21-28

It seems to be common to overlook the possibility that health workers can develop CVD. However, our study shows that 10% of workers have the chance a fatal or nonfatal vascular event at 10 years; according to the WHO recommendations for the assessment and management of cardiovascular risk, these workers should monitor their risk profile every twelve, six, or three months (the timing depends on the magnitude of this risk).²⁹

We believe that the main limitation of this study may be the fact that the workers included were from only two medical units of IMSS who came voluntarily to the Departamento de Fomento a la Salud, and that this does not represent what might happen in workers from other health institutions in Mexico. However, based on the results obtained, the sample of workers seemed similar to what has been reported by national health surveys, which could suggest that the results found in this work may be representative of the general population of workers. Moreover, the results of this study have important implications for promoting the participation of all stakeholders to monitor, improve, and maintain the health and welfare of workers and thus move towards a healthy work environment, where the quality of life of the entire population improves, since this is one of the most precious assets for individuals, communities, and countries.

In conclusion, the prevalence of CRF in health workers does not differ from that reported in the general population; 60% of workers have ≥ 3 CRF; the administrative area, nutrition/dieticians, and medical assistants are most associated with the risk of MS, obesity, and dyslipidemia. Ten percent of workers are likely to have a vascular event in the next 10 years. The need for evaluation and reorientation of health promotion programs in the workplace should be emphasized, and the adoption of multidisciplinary care is critical to the success, effectiveness, and sustainability of these programs.

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