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      Female sex and cardiovascular disease risk in rural Uganda: a cross-sectional, population-based study

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          Sex-based differences in cardiovascular disease (CVD) burden are widely acknowledged, with male sex considered a risk factor in high-income settings. However, these relationships have not been examined in sub-Saharan Africa (SSA). We aimed to apply the American Heart Association (AHA) ideal cardiovascular health (CVH) tool modified by the addition of C-reactive protein (CRP) to examine potential sex-based differences in the prevalence of CVD risk in rural Uganda.


          In a cross-sectional study nested within a population-wide census, 857 community-living adults completed physical and laboratory-based assessments to calculate individual ideal CVH metrics including an eight category for CRP levels. We summarized sex-specific ideal CVH indices, fitting ordinal logistic regression models to identify correlates of improving CVH. As secondary outcomes, we assessed subscales of ideal CVH behaviours and factors. Models included inverse probability of sampling weights to determine population-level estimates.


          The weighted-population mean age was 39.2 (1.2) years with 52.0 (3.7) % females. Women had ideal scores in smoking (80.4% vs. 68.0%; p < 0.001) and dietary intake (26.7% vs. 16.8%; p = 0.037) versus men, but the opposite in body mass index (47.3% vs. 84.4%; p < 0.001), glycated hemoglobin (87.4% vs. 95.2%; p = 0.001), total cholesterol (80.2% vs. 85.0%; p = 0.039) and CRP (30.8% vs. 49.7%; p = 0.009). Overall, significantly more men than women were classified as having optimal cardiovascular health (6–8 metrics attaining ideal level) (39.7% vs. 29.0%; p = 0.025). In adjusted models, female sex was correlated with lower CVH health factors sub-scales but higher ideal CVH behaviors.


          Contrary to findings in much of the world, female sex in rural SSA is associated with worse ideal CVH profiles, despite women having better indices for ideal CVH behaviors. Future work should assess the potential role of socio-behavioural sex-specific risk factors for ideal CVH in SSA, and better define the downstream consequences of these differences.

          Electronic supplementary material

          The online version of this article (10.1186/s12872-019-1072-9) contains supplementary material, which is available to authorized users.

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          Most cited references 20

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          The effects of physical activity on serum C-reactive protein and inflammatory markers: a systematic review.

          Physical activity is associated with a reduced incidence of coronary disease, but the mechanisms mediating this effect are not defined. There has been considerable recent interest in inflammation in the pathogenesis of cardiovascular disease. Some of the beneficial role of physical activity may result from its effects on the inflammatory process. We searched PubMed for articles published between 1975 through May 2004 using the terms exercise, physical activity, or physical fitness combined with C-reactive protein, inflammation, inflammatory markers, or cytokines. The review revealed 19 articles on the acute inflammatory response to exercise, 18 on cross-sectional comparisons of subjects by activity levels, and 5 examining prospectively the effects of exercise training on the inflammatory process. Exercise produces a short-term, inflammatory response, whereas both cross-sectional comparisons and longitudinal exercise training studies demonstrate a long-term "anti-inflammatory" effect. This anti-inflammatory response may contribute to the beneficial effects of habitual physical activity.
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            Estimating causal effects from epidemiological data.

            In ideal randomised experiments, association is causation: association measures can be interpreted as effect measures because randomisation ensures that the exposed and the unexposed are exchangeable. On the other hand, in observational studies, association is not generally causation: association measures cannot be interpreted as effect measures because the exposed and the unexposed are not generally exchangeable. However, observational research is often the only alternative for causal inference. This article reviews a condition that permits the estimation of causal effects from observational data, and two methods -- standardisation and inverse probability weighting -- to estimate population causal effects under that condition. For simplicity, the main description is restricted to dichotomous variables and assumes that no random error attributable to sampling variability exists. The appendix provides a generalisation of inverse probability weighting.
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              Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city.

              The American Heart Association Committee recently developed definitions of "ideal," "intermediate," and "poor" cardiovascular health based on 7 cardiovascular disease (CVD) risk factors or health behaviors. This study evaluated the prevalence of "ideal" American Heart Association cardiovascular health metrics from June 2006 to October 2007 in the Kailuan cohort (n=101 510; age 18-98 years) in northern China and its relationship with the 4-year CVD incidence. We used Cox proportional hazards regression to calculate hazard ratios and 95% confidence intervals for baseline health behaviors and risk factor categories. The majority of participants (63,676; 69.45%) presented with ≤3 ideal cardiovascular health metrics, whereas 8342 participants (9.1%) had 5 to 7 ideal metrics. Only 93 of 91,698 participants (0.1%) had all 7 metrics in the ideal range. There was a strong relationship between the cumulative incidence of CVD events in the 4-year follow-up and the number of ideal health metrics at baseline; the 1111 participants with 6 and 7 ideal metrics had a significantly lower cumulative incidence of CVD than subjects with no or only 1 ideal health metric (0.8% versus 3.3%). Men had higher rates of CVD events than women (2.46% versus 1.18%). Few adults had ideal cardiovascular health according to the modified American Heart Association definition. We detected a strong inverse relationship between the cumulative CVD incidence and the number of ideal health metrics at baseline. Population-wide prevention, especially lifestyle improvement, is critical to increase the low-risk prevalence and thereafter decrease CVD events. Clinical Trial Registration- URL: Unique identifier: ChiCTR-TNC-11001489.

                Author and article information

                +1 781 796 2985 ,
                BMC Cardiovasc Disord
                BMC Cardiovasc Disord
                BMC Cardiovascular Disorders
                BioMed Central (London )
                25 April 2019
                25 April 2019
                : 19
                [1 ]ISNI 000000041936754X, GRID grid.38142.3c, Harvard Medical School, ; 125 Shattuck St, Boston, MA 02115 USA
                [2 ]ISNI 0000 0004 0386 9924, GRID grid.32224.35, Massachusetts General Hospital, ; Boston, MA USA
                [3 ]ISNI 0000 0001 1955 1644, GRID grid.213910.8, Department of Health Systems Administration, , Georgetown University, ; Washington, DC USA
                [4 ]ISNI 0000 0001 0232 6272, GRID grid.33440.30, Mbarara University of Science & Technology, ; Mbarara, Uganda
                [5 ]Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
                [6 ]GRID grid.488675.0, Africa Health Research Institute, ; Durban, KwaZulu-Natal South Africa
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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