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��ࡱ�>��	~�����}��P�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������q`	��0ܿbjbjqPqP	��::iYA�������pppp����\.\.\.8�.�/���h��/000F03%313igkgkgkgkgkgkg$�jhHm��g�K�2@3KK�gpp0F0��h?R?R?RK^pR0(�F0ig?RKig?R?R��a|�"�9cF0�/����\.mN�abue��h0�hsb�&nOO�&n$9c&n�9c<93v�:T?R@DGD�939393�g�g�Qj939393�hKKKK���d(\.���\.���pppppp����Obesity and other Cardiovascular Risk Factors in Egyptian University Students: Magnitude of the Problem

Authors
Azza Farrag, MD, Cairo University, Cairo, Egypt
Azza El Eraky, MD, Suez Canal University, Ismailia, Egypt
Yasser Yazed, MD, Cairo University, Cairo, Egypt
Wafaa El Aroussy, MD, Cairo University, Cairo, Egypt
Ghada Sayed, MD, Cairo University, Cairo, Egypt
Ahmad Mahrous, MD, Cairo University, Cairo, Egypt
Ahmad Adel, MD, Cairo University, Cairo, Egypt
Abdel Moniem Ibrahim, MD, Cairo University, Cairo, Egypt
Mohsen Ibrahim, MD, Cairo University, Cairo, Egypt

Corresponding author
Azza Farrag, Department of Cardiovascular Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
e-mail:  HYPERLINK "mailto:azzaabdelmoniem@yahoo.com" azzaabdelmoniem@yahoo.com
Mobile: +2 010 1900014
Fax: +2 02 27948879










ABSTRACT
Background: Cardiovascular risk factors are usually tolerated at a younger age and barely perceived as harmful. However, over time, these risk factors can lead to excessive morbidity and mortality from cardiovascular events. Obesity in specific is rising among adolescents and young adults worldwide including populations living in developing countries. The aim of the study was to evaluate the prevalence of obesity and other cardiovascular risk factors in a group of university students representing a large sector of young adults in Egypt.
Methods: Data from these analyses were drawn from 10 public universities in 10 Egyptian governorates that represent different geographic areas in Egypt. A total of 2895 students were recruited for self-administered questionnaire, anthropometric and blood pressure measurements as well as laboratory analyses for random blood sugar and total cholesterol level.
Results: The majority of students were non smokers, but the minority performed regular physical exercise. Obesity was encountered in 13% of participants, while truncal obesity was shown in 47%. Obesity was more prevalent in South Upper Egypt students especially females. Eleven percent of students were shown to be hypertensives and 21% were pre-hypertensives. 
Conclusion: This report explored the prevalence of cardiovascular risk factors among large sector of Egyptian young adults. Hypertension and pre-hypertension were prevalent in this age group. Obesity, particularly the truncal type was very prevalent especially in females.

Key words: Cardiovascular risk factors; obesity; Egyptian young adults

INTRODUCTION
Worldwide, cardiovascular disease is estimated to be the leading cause of death and disability (1). Most of cardiovascular disease events nowadays are taking place in low and middle income countries with about 80% of the burden occurring in these countries (2). The INTERHEART study (3) showed striking variation in the age of first presentation of acute myocardial infarction in various regions of the world, with the youngest patients in the region of the Middle East (median age 51 years). The highest proportion of cases with first acute myocardial infarction at age 40 years or younger was also in men from Middle East (12.6%).
The development of major cardiovascular risk factors at an early age is closely related to clustering of risk factors and health behavior. Hypertension, dyslipidemia, glucose intolerance and overweight are usually tolerated at a younger age, however, overtime these conditions especially if associated with poor dietary habits, smoking or physical inactivity; can lead to excessive morbidity and mortality from cardiovascular disease later in adulthood (4). Exposure to these risk factors early in life was shown to induce permanent changes in the arterial tree that eventually leads to development of atherosclerosis (5, 6). Although considered rare in adolescents and young adults, the levels of these risk factors were shown to be correlated with those observed later in adult life (7-9).
In Egypt, since 1990, the cardiovascular related mortality was increased over three folds; to be responsible for over 40% of deaths compared with 12% reported two decades earlier (10). The Egyptian National Hypertension Project (NHP) (11, 12) was conducted between year 1991 and 1993 in six Egyptian governorates to define the prevalence of cardiovascular risk factors in adult Egyptians. The project documented an extremely high prevalence and prominent clustering of cardiovascular risk factors in adult men and women particularly obesity.
Very little is known about the prevalence and trends of cardiovascular risk factors among adolescents and young adults in Egypt. This study was conducted to determine the prevalence of measurable parameters (blood pressure, obesity indices, serum cholesterol and random blood sugar) and behavioral trends (physical activity, smoking and dietary habits) among group of Egyptian university students below age 25 years with a specific focus on the pattern of obesity and its relation to different geographical areas in Egypt.

SUBJECTS and METHODS
Design
Data for these analyses were drawn from 10 public universities in 10 Egyptian governorates that represent different geographic areas, and urban and suburban areas; 1 in the capital region (Cairo University), 3 in the Delta region (Banha, Zagazig and Monufia Universities), 2 representing coastal region (Alexandria and Suez Canal Universities), 2 representing North Upper Egypt (Beni Suef and Minya Universities) and 2 representing South Upper Egypt (Asyut and Sohag Universities). Private universities were not included in this survey because it was thought that it would tend to include students with higher socioeconomic background. Students from faculty of Medicine, Oral Medicine, Physical Medicine, Pharmacy and Nursing were not included in this survey.
One month earlier, different university students in the 10 governorates were clearly announced about details of this study by posters and flyers. At the day of recruitment, the first 2 to 3 hundred students presented to the local working group office were included in the sampling frame.
Written informed consent was obtained from all participants, and the study protocol was approved by the ethical committee of our institution.
Participants 
Participants were 2895 (mean age 20.2 � 1.8 years), with female gender preponderance (62.3%). The survey included a self-administered questionnaire, anthropometric and blood pressure (BP) measurements and laboratory analysis of blood samples.
The student questionnaire consisted of precoded answers about demographic characteristics including, age and gender, use of tobacco (cigarettes), physical activity and dietary habits. Participants reported any tobacco use as  tobacco use-ever  and those reported no use as  tobacco use-never . Data on frequency of participation in physical activity were collected. Participants were asked to report the number of days per week they performed different types of exercise (e" 4 days / week, 2-3 days / week or once / week). Periods of exercise were expressed as e" 30 minutes or < 30 minutes. Consumption of vegetables and fruits was expressed as the number of servings per day (> 6 servings / day, 3-6 servings / day or < 3 servings / day). One serving of vegetables or fruits was defined as small plate of cooked vegetables, small plate of salad or one piece of fresh vegetables or fruits. 
Anthropometric measurements
Height was measured to the nearest millimeter using portable height scales with shoes removed. Weight was measured to the nearest 0.1 Kg using portable bathroom scales with student shoes and heavy clothing removed. Height and weight measurements were used to calculate body mass index (BMI) according to the formula: BMI = weight (kg) / height (m2). Overweight was defined as BMI 25-29.9 and obese as BMI e" 30 Kg/ m2. Waist circumference was measured at the midpoint between the bottom of the rib-cage and the top of the lateral border of iliac crest during minimal respiration. Waist-to-height ratio (WHtR) was calculated with central obesity defined as WHtR e" 0.5 (13).
	Blood pressure (BP) was measured after 5 minutes rest, in the sitting position from the right arm using standard mercury sphygmomanometers. The appearance of Korotcoff sounds was taken as systolic BP and the Korotcoff fifth phase (the disappearance of sounds) was recorded as the diastolic BP. Two measurements were made for all participants at 2 minutes intervals with the average of 2 measurements used in data analysis. Hypertension was defined as BP >140 / 90 mmHg and pre-hypertension as BP d" 140 /90 - e" 130 / 85 mmHg. 
Blood samples and biochemical analysis
To measure random blood sugar and serum total cholesterol, a venous blood specimen of non-fasting participants was taken in a sitting position using well calibrated digital machines. 
Statistical analysis
Data on every item in the questionnaire or anthropometric measurements were not available for each participant. Thus all calculations were based upon those participants with data for a given item. For the descriptive purposes, categorical data were presented as absolute frequencies and percentages. Pearson Chi-square test was used to compare categorical data. To represent differences in the pattern of obesity among different geographical areas in Egypt, we considered the 5 main regional areas; the capital area, the Delta region, Coast, North Upper Egypt and South Upper Egypt for comparison. All statistical analyses were performed with SPSS 14.0.1 program (SPSS, Chicago, IL).

RESULTS
Questionnaire data were complete in 2312 participants. Some missing data were noticed in 270 sheets as shown in table 1. Most students (> 90%) belonged to �tobacco use-never  group. Less than 15% had regular exercise e" 4 days / week, however, most students when performing exercise, they made it for e" 30 minutes. About 90% of students had d" 6 daily servings of vegetables and fruits.
	
Table 1. Questionnaire Data of all participants
Number (%)Total numberMale gender
Smoking 
Tobacco use-ever
Tobacco use-never
Physical exercise
> 4 days / week
2-4 days / week
Once / week
Period of exercise e" 30 minutes 
Period of exercise < 30 minutes 
Dietary habits
> 6 servings of vegetables and fruits / day
3-6 servings of vegetables and fruits / day
< 3 servings of vegetables and fruits / day1092 (37.7)

193 (7.1)
2515 (92.9)

384 (14.6)
683 (26.0)
1558 (59.4)
1909 (72.7)
986 (37.3)

273 (10.1)
1303 (48.4)
1118 (41.5)2895
2708


2625





2694



Table 2. Valid data of blood pressure and anthropometric measurements
Number of students (%)Total numberBlood pressure
> 140 /90 mmHg
d" 140 /90 - e" 130 / 85 mmHg
< 130 / 80 mmHg
BMI
 Normal (< 25 kg / m2)
Overweight (25   29.9 kg / m2)
Obese (e" 30 kg /m2)
WHtR
< 0.5
e" 0.5
300 (11.3)
557 (21.0)
1795 (67. 7)

1369 (59.2)
635 (27.5)
308 (13.3)

1222 (52.9)
1090 (47.1)2652



2312



2312

BMI, body mass index; WHtR, waist-to-height ratio


	Table 2 shows the valid data for BP and anthropometric measurements. Eleven percent of students were shown to have BP > 140 / 90 mmHg. However, 21% were considered pre-hypertensives. According to BMI, obesity and overweight were shown in 13% and 27% of students respectively; while3 truncal obesity (WHtR e" 0.5) was present in 47%.	
	Random blood sugar measurements were done for 2375 students. Levels e" 200 mg% were shown in only 32 (1.3%) participants. Measurement of total cholesterol levels were done for students of only 4 universities (Cairo, Beni Suef, Suez Canal and Monufia). Out of 796 blood samples studied, only 68 (8.5%) showed results e" 200 mg%. 










Figure1. Frequency of physical exercise performed by students in different geographical areas in Egypt

Table 3 shows the pattern of obesity in different geographical areas in Egypt. Obesity (BMI e" 30) was shown to be more prevalent in Delta and South Upper Egypt. However, truncal obesity (WHtR e" 0.5) was shown to be more prevalent in Cairo and also South Upper Egypt. As shown in figures 1 and 2, students from Coast and Delta regions were the least to perform regular exercise. However, these students reported the highest prevalence of consumption of vegetables and fruits as 3-6 servings / day.
Table 4 shows the gender distribution of truncal obesity in different geographical areas. Truncal obesity was shown in 38.8% of male students and in 51.7% of female students. Male students from Cairo and South Upper Egypt had the highest and lowest prevalence of truncal obesity respectively. On the other hand, female students from South Upper Egypt and North Upper Egypt had the highest and lowest prevalence of truncal obesity respectively.


Table 3. Patterns of obesity in different geographical areas in Egypt
BMI
(n= 2312)WHtR
(n= 2312)NormalOverweightObeseNo truncal obesityTruncal obesityCairo
Delta
Coast
NUE
SUE111 (59.7)
251 (47.9)
340 (63.4)
481 (63)
186 (61.6)50 (26.9)
179 (34.2)
133 (24.9)
202 (26.4)
71 (23.5)25 (13.4)
94 (17.9)
63 (11.7)
81 (10.6)
45 (14.9)76 (40.9)
249 (47.5)
275 (51.3)
500 (65.4)
122 (40.4)110 (59.1)
275 (52.5)
261 (48.7)
264 (34.6)
180 (59.6)BMI, body mass index; WHtR, waist-to-height ratio; NUE, North Upper Egypt; SUE, South Upper Egypt











Figure2. Daily servings of vegetables and fruits consumed by students in different geographical areas in Egypt



Table 4. Gender distribution of truncal obesity in different geographical areas in Egypt
Male students
(n = 847)Female students
(n = 1465)No truncal obesityTruncal obesityNo truncal obesityTruncal obesityCairo
Delta
Coast
NUE
SUE35 (39.3)
83 (63.4)
58 (59.8)
252 (64.1)
90 (69.8)54 (60.7)
51 (36.6)
41 (40.2)
144 (35.9)
39 (30.2)42 (43.3)
166 (42.6)
218 (49.9)
250 (67.9)
32 (18.5)55 (56.7)
224 (57.4)
219 (50.1)
118 (32.1)
141 (81.5)NUE, North Upper Egypt; SUE, South Upper Egypt

	
DISCUSSION
In this survey, questionnaire data revealed that > 90% of participants were non smokers, 60% perform physical exercise once weekly for at least 30 minutes, and only 10% consumed > 6 daily servings of vegetables and fruits. BP and laboratory measurements showed that > 65% of students were normotensives and only 1.3% and 8.5% had RBS and total cholesterol e" 200 mg% respectively.
A previous report on Egyptian adolescents (766 participants) showed that 80% were non smokers (14). However, the Egyptian NHP in 1993 showed 43% of studied adult populations were smokers (12). Taken into account, the possible underreporting of smoking among adolescents and young adults, the most logic explanation of low prevalence of tobacco smoking in this group is the limited purchasing power.
On measuring BP, 11% were found to be hypertensives. This is much less than the prevalence in adults (26.3%) according to Egyptian NHP (12). Reports from other developing countries showed significant decrease in BP among adolescents. This was explained by the changes in lifestyle such as diet and physical activity rather than improved hypertension control (15).
The prevalence of diabetes and hypercholesterolemia in our study group was also lower than adult population of the Egyptian NHP (12) (1.3% and 8.5% vs. 7.9% and 12.2% respectively).
	Our study showed obesity and overweight to have a prevalence rate of 13% and 27.5% respectively, however, truncal obesity was shown in 47% of participants. Female students suffered truncal obesity at a higher rate compared to male students (51.7% vs. 38.8%). This is nearly matching the data from Egyptian NHP (12) where truncal obesity was shown in 57.8% of adult females vs. 37% of adult males. The high prevalence of obesity in our studied group of young adults may be related to lack of routine health visits and decreased role of primary care physicians to provide opportunistic counseling regarding weight management. In addition, screening for cardiovascular risk factors including obesity may not be feasible or affordable for most individuals at this age group. Taking into account the lack of regular physical exercise and the decreased intake of fiber-rich diet of most of our participants, could help better understanding of high prevalence of obesity.
Although BMI is the most studied index, being significantly related to CVD risk factors as demonstrated by cross-sectional and prospective studies (3, 16), there are increasing doubt about its role in predicting CVD risk factors which has led to an increasing evidence for abdominal obesity indices. A computed tomography study demonstrated that WHtR showed the highest correlation with intra-abdominal fat compared to BMI, waist circumference and waist-to-hip ratio (17). WHtR was first used in the Framingham study (18) and proved to be weakly associated with age. We used this index to test truncal obesity in different geographical areas in Egypt and its gender distribution.
Among all Egyptian university students, SUE had the highest prevalence rate of truncal obesity particularly in females. On the other hand; NUE was shown to have the lowest prevalence of truncal obesity and also the lowest prevalence of obesity according to BMI. The questionnaire data showed NUE students to perform the highest prevalence of regular exercise for (e" 4 days / week). In addition, near 50% of them consumed >3 servings of vegetables and fruits / day. We do not have clear explanation for the increased prevalence of truncal obesity in SUE. However, we consider certain traditions preventing young adult females in this geographical area from participating in regular exercise program to be the most likely explanation. In addition, the possibility of being at home for more hours, watching television for example, may add a contribution to increasing body fat overtime (19). 
The clustering of cardiovascular risk factors among young adults in Egypt needs effective preventive measures to be implemented, because today�s adolescents and young adults with their relatively low risk factor prevalence, will be tomorrow�s adult with higher prevalence of risk factors and ultimately patients suffering cardiovascular disease. Public health service should be designed for promoting healthy lifestyles and preventive programs tailored to different age groups in the community.
Limitations
Because the sample was taken from non-medical university students, this could not be representative to the whole sector of young adults in Egypt. The different socioeconomic and educational classes should be considered in the future research.

CONCLUSION
This is one of the few reports exploring the prevalence of cardiovascular risk factors among young adults in Egypt. Hypertension and pre-hypertension were prevalent in our study population. Obesity, particularly, the truncal type was very prevalent especially in females. The frequency of performing regular exercise was quite low. The identification of the existence of these risk factors, can contribute to the development of preventive strategies which should be adapted to the socio-culturalMghipq�������������		@	A	L	q	�	�	>
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ACKNOWLEDGMENT
This study was supported by the Egyptian Hypertension Society. It was a joint effort of many investigators and staff members in 10 universities whose contributions are gratefully acknowledged. We thank (in alphabetical order) Prof. Dr. Ahmad El Hawwary, Suez Canal University; Prof. Dr. Aly Kassem, Sohag University; Prof. Dr. Ashraf Reda, Monufia University; Prof. Dr. Hesham Abou El Enein, Banha University; Prof. Dr. Hesham Boshra, Beni Suef University; Prof. Dr. Mahmoud Hasaneen, Alexandria University; Prof. Dr. Mohammad Wafae, Zagazig University; Prof. Dr. Nasser Taha, Minya University; Prof.Dr. Soliman Ghareeb, Cairo University; and Prof. Dr. Yehia Keshk, Asyut University. We also thank all university students for their participation.

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