RESEARCH ARTICLE


The Effect of Lifestyle on Hypercholesterolemia



Dewi Febriani*, Besral
Department of Biostatistics and Population, Faculty of Public Health, University of Indonesia, Depok, Indonesia


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© 2018 Febriani et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Biostatistics and Population, Faculty of Public Health, University of Indonesia, Indonesia; Tel: +6281218394149; E-mail: iwed_boezzz@yahoo.com


Abstract

Background:

Unhealthy lifestyle is a risk factor for hypercholesterolemia. However, the study about lifestyle and hypercholesterolemia in Indonesia is not completely explored.

Objectives:

The present study attempted to examine the effect of lifestyle on hypercholesterolemia including smoking habits, physical activity, consumption of vegetables and fruits.

Methods:

This study employed the data from Integrated Coaching Post (Posbindu) Non-Communicable Disease in DKI Jakarta Indonesia 2015- with a sample size of 1090 participants analyzed using multivariable binomial regression. The potential impacts were also measured to determine the contribution of risk factors.

Result:

The prevalence of hypercholesterolemia was 49,5%. The results of a multivariate analysis -highlighted that physical activity and smoking habits determined the lifestyle associated with hypercholesterolemia-. Less physical activity -contributed- significantly to hypercholesterolemia.

Conclusion:

The prevalence of hypercholesterolemia in this study was quite high. Physical activity and smoking habits were significant determinants of hypercholesterolemia.

Keywords: Consumption of vegetables and fruits, Hypercholesterolemia, Lifestyle, Smoking habits, Physical activity, Indonesia.



1. INTRODUCTION

Non-Communicable diseases are a source of national and global concern. Increased levels of cholesterol and fat in the blood cause narrowing or calcification of the arteries and are the main causes of cardiovascular disease. According to a WHO report, hypercholesterolemia is estimated to account for 18% of cerebrovascular disease and 56% of ischemic heart disease worldwide [1]. Overall, it is responsible for 4.4 million deaths (7.9%) and 40.4 million DALY (2.8%) [1]. The Multiple Risk Factor Intervention Trial showed that the risk of death from coronary heart disease began to increase at a cholesterol level of 180 mg/dl. The risk increased again at levels of 200 mg/dl and tripled at levels of 245 mg/dl.

According to the Basic Health Research report in 2013, the proportion of the population aged >15 years with total cholesterol levels above normal was 35.9%. In the same study, when the data were stratified according to sex and residential area, the figures were 39.6% and 30% for females and males, respectively, and 39.5% and 32.1% for urban and rural areas, respectively [2].

An unhealthy lifestyle can trigger hypercholesterolemia at a productive age. High-cholesterol foods, such as fatty meats, chicken skin, coconut milk, egg yolks, butter, cheese, fried foods, cakes and biscuits, in addition to a lack of physical activity, smoking habits, and alcohol consumption, can have adverse health effects and accelerate the onset of hypercholesterolemia [3].

This study applied the data of Integrated Coaching Post Non-Communicable Disease in Indonesia to determine the effect of lifestyle on hypercholesterolemia in DKI Jakarta Province in 2015-2016.

2. METHOD

An analytical cross-sectional study design was used to determine the effect of lifestyle on hypercholesterolemia in DKI Jakarta Province in 2015-2016. The dependent variable was cholesterol status, and the independent variables were smoking habits, physical activity and consumption of vegetables and fruits. Potential confounders included age, sex, education, employment status, familial history of hypercholesterolemia, blood sugar levels, blood pressure, and nutritional status.

Various risk factors used as research variables were derived from Integrated Coaching Post (Posbindu) Non-Communicable Disease in DKI Jakarta Indonesia activities which included the activity of extracting risk factor information with simple interviews about non-communicable disease history in the family and the participants themselves, physical activity, smoking, lack of eating vegetables and fruits. This activity is carried out during the first visit and periodically once a month. Activities measuring body weight, height, Body Mass Index (BMI), abdominal circumference, blood pressure, blood sugar levels, cholesterol levels are held once a month.

The population consisted of all participants in the Integrated Coaching Post Non-Communicable Disease in DKI Jakarta in 2015-2016. The inclusion criteria were: a) the Integrated Coaching Post Non-Communicable Disease participants who had a blood cholesterol level check and b) Integrated Coaching Post Non-Communicable Disease participants with the first visit. If the participant had visited Posbindu more than once in a single year, the blood cholesterol level on the first visit was recorded. The exclusion criteria were Posbindu participants who had a history of hypercholesterolemia. Based on the inclusion and exclusion criteria, 1,090 individuals were included in the study.

The data were analyzed using multivariable binomial regression. The potential impacts of physical activity, smoking habits and consumption of vegetables and fruits levels on the variables were also measured to determine the contribution of each factor to the risk of hypercholesterolemia.

3. RESULTS

3.1. Hypercholesterolemia Prevalence

Cholesterol levels measured were the total cholesterol levels. The prevalence of hypercholesterolemia in DKI Jakarta Province was 49.5%.

3.2. Relation of Respondent Characteristics with Hypercholesterolemia

Hypercholesterolemia was more prevalent in respondents with a smoking habit (78.7%), with an inadequate level of physical activity (69.7%), and insufficient level of vegetable and fruit consumption (55.3%). Hypercholesterolemia was more common among elderly (46-65 years) respondents (64.6%) and males (65.1%). More respondents with a high level of education (62.5%) had hypercholesterolemia. In terms of employment status, the proportion of respondents with hypercholesterolemia was higher among employed (53.2%). The proportion of respondents with hypercholesterolemia was lower among those who had a familial history of hypercholesterolemia than among those who did not -have- a familial history of the disorder (40.1% vs. 51.4%).

In terms of other noncommunicable disease risk factors, hypercholesterolemia was higher in hypertensive respondents (69.4%). the proportion of hyperglycemic respondents with hypercholesterolemia (73.5%). The proportion of obese respondents with hypercholesterolemia was 67.6%.

Table 1. Relation of Respondent Characteristics with Hypercholesterolemia.
- Cholesterol Levels - - - - - - -
- Normal - Hypercholesterolemia - Total RR 95%CI P Value
Variable n % n % - - - -
Smoking Habit - - - - - - - -
Do not smoke 458 66,6 200 30,4 658 Ref - -
Smoke 92 21,3 216 78,7 432 2,5 2,3-3,0 0,001
Physical Activity - - - - - - - -
Enough 328 91,9 29 8,1 357 Ref    
Less 22 30,3 511 69,7 733 8,5 6,0-12,2 0,001
Consumption of Vegetables and Fruits - - - - - - - -
Enough - - - - - - - -
Less 169 71,0 69 29,0 238 Ref    
Age 381 44,7 471 55,3 852 1,9 1,5-2,3 0,001
12-25 years old (Adolescents) - - - - - - - -
26-45 years old (Adults) 129 71,3 52 28,3 181 Ref - -
46-65 years old (Elderly) 271 55,9 214 44,1 485 1,5 1,2-2,0 0,001
Sex 150 35,4 274 64,6 424 2,2 1,8-2,9 0,001
Female - - - - - - - -
Male 390 61,8 241 38,2 631 Ref - -
Education 160 34,9 299 65,1 459 1,7 1,5-1,9 0,001
Higher Education - - - - - - - -
Secondary Education 108 37,5 180 62,5 288 Ref - -
Primary Education 268 56,8 204 43,2 472 0,7 0,6-0,8 0,001
Employment 174 52,7 156 47,3 330 0,8 0,5-0,9 0,001
Do not work - - - - - - - -
Work 187 59,5 127 40,5 314 Ref - -
Hypercholesterol History 363 46,8 413 53,2 776 1,3 1,1-1,5 0,001
in the Family - - - - - - - -
Has no history - - - - - - - -
Has history 444 48,6 469 51,4 913 Ref - -
Blood Pressure 106 59,9 71 40,1 177 0,8 0,7-0,9 0,011
Normal - - - - - - - -
Hypertension 395 67,8 188 32,2 583 Ref - -
Blood Sugar Level 155 30,6 352 69,4 507 2,2 1,9-2,5 0,001
Normal - - - - - - - -
Hyperglycemia 461 61,1 293 38,8 754 Ref - -
Nutritional Status 89 26,5 247 73,5 336 1,9 1,7-2,1 0,001
Normal - - - - - - - -
Obesity 351 73,9 124 26,1 475 Ref - -
- 199 32,4 416 67,6 615 2,5 2,2-3,0 0,001

3.3. The Effect of Lifestyle on Hypercholesterolemia

The results of a multivariate analysis revealed that physical activity showed a stronger association with hypercholesterolemia than did smoking and fruit and vegetable consumption. Respondents with an inadequate level of physical activity had 5.9 times higher risk of hypercholesterolemia (95% CI 4.1-8.4). Respondents who smoked had 1.4 times higher risk of hypercholesterolemia (95% CI 1.3-1.6). There was no statistically significant relationship between fruit and vegetable consumption and hypercholesterolemia (P = 0.762).

Table 2. Effect of Lifestyle on Hypercholesterolemia Risk.
Variable RR 95%CI P Value
Smoking Habit - - -
Yes Ref - -
No 1,4 1,3-1,6 0,001
Physical Activity - - -
Enough Ref - -
Less 5,9 4,1-8,4 0,001
Consumption of Vegetables and Fruits - - -
Enough Ref - -
Less 1,0 0,9-1,2 0,762
Blood Pressure - - -
Normal Ref - -
Hypertension 1,3 1,1-1,4 0,001
Nutritional Status - - -
Normal Ref - -
Obesity 1,4 1,3-1,6 0,001

3.4. The Potential Impact

The results of the potential impact measurement showed that an inadequate level of physical activity was the most likely cause of 56.4% (95% CI 50.7-61.6%) of cases of hypercholesterolemia in the exposed group and 78.2% (95% CI 69.5-84.5%) of cases of hypercholesterolemia in the population. Smoking habits accounted for 20.8% (95% CI 14.4-27.0%) of cases of hypercholesterolemia in the exposed group and 17.0% (95% CI 11.4-2-2.3%) of cases of hypercholesterolemia in the population.

Table 3. Calculation of Attributable Fraction Value in Exposed Group (AFE) and Population Attributable Fraction (PAF) Smoking Habit and Physical Activity with Hypercholesterolemia.
Variable AFE% 95%CI PAF% 95%CI
Smoking Habit 20,8 14,4-27,0 17,0 11,4-22,3
Less Physical Activity 56,4 50,7-61,6 78,2 69,5-84,5

4. DISCUSSION

Based on the results of the analysis, the prevalence of hypercholesterolemia was higher (49.5%) than the national rate (35.9%). The increase was explained by the high level of living competition in DKI Jakarta in Indonesia. The latter may lead to changes in lifestyle-related factors, such as food habits, physical activity, stress, smoking, and alcohol consumption, all of which may culminate in the emergence of health problems [4, 5].

The prevalence of hypercholesterolemia is high in almost all countries. In a survey in 1998-2007 of 79,039 adults aged 40-79 years in the U.K., Germany, Japan, Jordan, Mexico, Scotland, Thailand, and the U.S., the highest prevalence of hypercholesterolemia was in Thailand (78%), and the lowest was in the U.S. (16%) [6]. A study in Brazil (n = 2,471) reported a prevalence of 61.9% [7]. A study on 52,601 women in China reported that the prevalence of hypercholesterolemia was 40% [8].

In this study, respondents with an inadequate level of physical activity had a 5.9 times higher risk of hypercholesterolemia (95% CI 4.1-8.4) and those who smoked had a 1.4 times higher risk of hypercholesterolemia (95% CI 1.3-1.6) The findings of the present study are in line with those of Nindriani et al., who found that the number of cigarettes smoked (P = 0.010, odds ratio [OR] = 10), smoking duration (P = 0.027, OR = 7.5), and exercise habits (P = 0.010, OR = 9.6) were associated with the total cholesterol level [9]. Other research also reported that heavy smoking (OR = 2.5, 95% CI 1.6-4.0) and physical activity (OR = 1.2, 95% CI 1.0-1.34) were related to cholesterol levels [10].

In a study by Gordon et al. in 1983 of 7,106 individuals aged 35–59 years, the authors reported that physical activity significantly (P = 0.0001) predicted the total cholesterol level after controlling for age, body mass index, smoking habits, and alcohol consumption [11]. In the ATTICA study in Athens, Greece, a nutrition and health survey showed that the level of physical activity of rural inhabitants was higher than that of an urban population (55% vs. 45%) (P = 0.02) and that individuals with a higher level of activity had a 48% lower chance of being obese (95% CI 0.42-0.64) after controlling for sex, smoking habits, blood pressure, total cholesterol, and blood sugar [12].

In a study conducted in 2003, Lee et al. reported a relationship between physical activity and the risk of coronary heart disease (P = 0.002) [13]. In a study in 2012 of 3,148 individuals, in which 30% of the participants had hypercholesterolemia, the authors reported that physical fitness and the body mass index were associated with hypercholesterolemia [14]. In the study, undertaking physical exercise once or twice a week decreased the incidence of hypercholesterolemia by 12%. Conversely, an increase of one unit of body mass index increased the incidence of hypercholesterolemia by 18%. Williams also reported that the odds of hypercholesterolemia decreased in accordance with the amount of physical activity performed [15]. In the same study, the prevalence of males with hypercholesterolemia was 12.2% versus 5.14% in females. Fatima and Kartini reported that physical exercise habits were an important factor in the control of blood cholesterol levels when compared with that of the amount and type of fat in the diet [16]. In the same study, families who consumed dietary sources of fat but undertook regular exercise had the same blood cholesterol levels as those of families who consumed low-fat foods but undertook little physical activity. Saputri reported a significant difference between total cholesterol in the blood before and after low-impact aerobic exercise (P = 0.001) [17].

A study conducted by Health Advancement Services (n = 2,840 male adults) to determine the relationship between smoking and hypercholesterolemia found that males who consumed tobacco had an RR of 2.51 (95% CI 1.47-4.29) as compared with RRs of 1.51 (95% CI 1.14-2.00) and 1.98 (95% CI 1.29-3.03) for those who smoked 1-20 cigarettes a day and > 20 cigarettes a day, respectively [18]. In the study, the confounder variables were age, education, physical activity, and body mass index.

The present study also investigated the relationship between fruit and vegetable consumption and hypercholesterolemia. The results revealed no relationship between this variable and hypercholesterolemia. However, previous studies pointed to a strong relationship between fruit and vegetable consumption and hypercholesterolemia.

In addition to smoking habits and inadequate physical activity, other causes of hypercholesterolemia in this study were nutritional status and blood pressure. Respondents who were obese had 1.4 times higher risk of hypercholesterolemia (95% CI 1.3-1.76) and respondents with hypertension had 1.3 times higher risk of hypercholesterolemia (95% CI 1.1-1.4). A prospective study that included 48,287 males and females found an increased risk of death from coronary heart disease in males due to obesity (RR = 1.5, 95% CI 1.1-2.0), with smoking, hypertension, hypercholesterolemia, and diabetes mellitus as confounding variables [19]. Hasrulsah and Muhartono also found a relationship between obesity and cholesterolemia [20]. Given that risk factors for obesity can be modified, the development of preventive initiatives is warranted. Raising awareness of the importance of diet and the value of consuming healthy food can help modify obesity [21].

In this study, based on the results of a potential impact analysis, the Attributable Fraction in the Exposed group (AFE) value for hypercholesterolemia caused by smoking habits was 20.8%. This means that the incidence of hypercholesterolemia in the exposed group (smokers) could be reduced by 20.8% if smoking habits were eliminated. The Population Attributable Fraction (PAF) value for smokers was 17.0%, indicating that the smoker population contributed to the incidence of hypercholesterolemia by 17.0%. In other words, if smoking habits were eliminated in the population, hypercholesterolemia could be reduced by 17.0%. The AFE value for hypercholesterolemia attributed to inadequate physical activity was 56.4%. This means that the incidence of hypercholesterolemia in the exposed group (a reduced level of physical activity) could be reduced by 56.4% if smoking habits could be eliminated. The PAF value for those with a reduced level of physical activity was 78.2%, indicating that the population with an inadequate level of physical activity contributed to 78.2% of the incidence of hypercholesterolemia. In other words, if the level of physical activity in the population could be increased, hypercholesterolemia could be reduced by 78.2%.

Promotional and preventive efforts are very effective in the prevention of high morbidity and mortality from noncommunicable diseases. As disease prevention is highly dependent on individual behavior, supported by environmental quality, availability of facilities and infrastructure, and regulatory support for healthy living, continuous active involvement of all components of both central and local government, the nongovernmental sector, and society is required. For that, a movement to encourage people to behave healthy is needed.

CONCLUSION

The prevalence of hypercholesterolemia in this study was quite high. Physical activity and smoking habits were significant determinants of hypercholesterolemia. Inadequate physical activity most contributed to hypercholesterolemia in the exposed group and the population.

ETHICAL APPROVAL AND CONSENT TO PARTICIPATE

The ethical clearance of this study was granted by The Ethics Commission for Research and Public Health Service – Faculty of Public Health, University of Indonesia with the certificate of approval number 114/UN2.F10/PPM.00. 02/2017, dated April 18, 2017.

HUMAN AND ANIMAL RIGHTS

No humans/animals were used for the studies that are basis of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

I thank the Directorate General of Disease Prevention and Control of Ministry of Health for the data, and my colleagues who spend their time to proofread this work

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