Review of Global Medicine and Healthcare Research

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1 Review of Global Medicine and Healthcare Research Volume 2 Number 1 (2011) Publisher: DRUNPP Managed by: IOMC Group Website:

2 Prevalence of risk factors for non-communicable diseases Budimka Novaković (1) *, Jelena Jovičić (1), Mirjana Martinov-Cvejin (2), Biljana Božin (1), Maja Grujičić (1), Dušan Đurić (3), Neda Lakić (1), Vesna Mijatović-Jovanović (2) (1) University of Novi Sad, Faculty of Medicine, Serbia (2) Institute of Public Health of Vojvodina, Novi Sad, Serbia (3) University of Kragujevac, Faculty of Medicine, Serbia * Corresponding author; budimka@uns.ac.rs ABSTRACT Background: Number of cases of noncommunicable diseases (NCDs) is on the rise. Taking into account their multicausal etiology, it is important to determine the prevalence of risk factors for noncommunicable diseases in different regions and countries in order to plan adequate preventive actions. Aims and objectives: The aim of the study was to determine the prevalence of risk factors for NCDs such as overweight and obesity, high risk waist circumference, hyperglycemia and high blood pressure among individuals, aged 45 and older, living in the Autonomous Province of Vojvodina, according to their sex, age, level of education. Methods/Study design: The study included gathering of the following data: general and demographic data, anthropometric measurements (body height [cm], body mass [kg], waist circumference [cm]) and calculated body mass index (BMI) [kg/m 2 ], values of systolic blood pressure and diastolic blood pressure [mmhg] and fasting glycemia [mmol/l]. General and demographic data were gathered using a questionnaire and an interview and included sex, age, educational attainment and type of settlement. Anthropometric characteristics were measured and interpreted in accordance with WHO Guidelines. A logistic model was used to determine the ODDS ratio for each risk factor and it was used for classification of risk factors for hyperglycemia and NCD development. Data was collected from inhabitants of the Autonomous Province of Vojvodina (APV) of both sexes, aged 45 years and older. Results/Findings: Calculating of BMI showed that 74.3% of the APV population was overweight or obese, and that 33.3% was obese. More men were overweight and more women were obese. The highest prevalence of overweight was among women and men older than 60 years. Individuals with college or university degree were less likely to be obese than individuals with no elementary education or partial elementary education. The obtained results showed that close to 80% of the examined population of AP Vojvodina had a desirable waist circumference (WC). High-risk and stage II WC were more frequent in women, whereas stage I WC was more frequent in men. A desirable waist circumference was more frequent among college and university graduates compared to those with lower levels of education. The prevalence of individuals with normal blood pressure (BP) according to the Helsinki Commission recommendations was 46.5%. Using JNC 7 criteria, 65.6% of the APV population was found to be affected by hypertension. Hyperglycemia was more frequent among women and diabetes mellitus was more frequent among men. The number of individuals with fasting hyperglycemia and diabetes mellitus increased with age and among the eldest there were 37.1% of individuals with fasting hyperglycemia, and 15.2% with diabetes. Fasting hyperglycemia and diabetes mellitus were more frequent in individuals without or with partial elementary school, consistent with the findings from USA. Conclusion: Risk factors for NCDs are more often present among inhabitants of APV with lower education levels. Older age resulted in multiple risk factors presence. Almost half of the population of AP Vojvodina older than 45 years (46%) had three or four diet-related risk factors for NCDs. Actions should be taken in APV in order to reduce the future social and economic burden of NCDs in AP Vojvodina. Keywords: Non-communicable diseases, chronic diseases, risk factors, BMI, waist cifcumference, glycemia Vol. 2 No 1 (2011) Page 58

3 Background: Unhealthy eating habits are the leading cause of 41% of mass non-communicable diseases (NCDs) and a contributing factor for 38% of NCD cases. Only 21% of NCDs are not diet-related. 1,2 According to World Health Organization (WHO), NCDs and insufficient physical activity accounted for 19.1% of deaths worldwide and 7% of disability-adjusted life years (DALYs). 3 Out of all NCDs, hypertension is the leading cause of death (12.8% of global deaths; 3.8% DALYs), followed by high blood glucose (5.7% of global deaths; 2.7% of DALYs), overweight and obesity (4.8% of global deaths; 2.4% DALYs). 3 Global health-care expenditure for NCDs is enormous and evergrowing. 4,5 It is reported that overweight and obesity are reponsible for about 80% of cases of type 2 diabetes, 35% of ischaemic heart disease and 55% of hypertensive disease among adults in Europe. 6 WHO and Centers for Disease Control and Prevention (CDC) record the growth of daily energy intake. According to CDC, in developed countries, daily energy intake in 1964 was 2947 kcal per capita and is projected to reach 3440 kcal per capita in the year In developing countries, the projected rise over the same period of time is even more striking from 2054 kcal/capita/day to 2850 kcal/capita/day. 7 WHO reported that 1.6 billion people are overweight or obese and that 400 million are obese. 8 In the Republic of Serbia, daily energy intake rose from 2643 kcal/capita to 3864 kcal/capita from 1993 to 2001, with total lipids accounting for 35% of energy consumed. 9 Together with insufficient physical activity and other unheatlhy lifestyle choices, high energy-dense nutrition, as a known risk factor for overweight, obesity (and other NCDs), resulted in 54.5% of adults in Serbia being overweight. 10 Population of Serbia and AP Vojvodina, as one of its regions, is burdened the most by NCDs, especially cardiovascular diseases with high blood pressure being the most dominant NCD (46.5% of the population of Serbia) and, at the same time, risk factor for other NCDs. 10 There are substantial numbers of cohort studies showing that, for individuals, the lowest risk of diabetes, hypertension and other conditions may be at BMIs lower than Age (65 and over), BMI 25, increased waist circumference, elevated blood pressure (systolic 120 mmhg or diastolic 80 mmhg) are significant risk factors for development of NCDs. Educational attainment affects food choices and lifestyle choices, resulting in greater prevalence of overweight and obesity, especialy central obesity (visceral adiposity; high risk waist circumference) among individuals with lower levels of education. 7 In the United States, for both men and woman obesity prevalence was the lowest among those with college education, and prevalence was greatest among those who did not graduate from high school. 12 High risk waist circumference is a known risk factor for the development of NCDs. Adipose tissue, particulary tissue from visceral-fat deposits is responsible for patophysiological events such as increased lipolitic activity, levels of IL-6, TNF-α, CRP and macrophage infiltration in the development of chronic diseases which can explain why abdominal fat distribution is related to the risk of death. Body mass is more closely related to the amount of visceral fat in men than in woman. 13 Global prevalence of impaired fasting glucose and impaired glucose tolerance are 54% and 10% respectively. 14 Today, type 2 diabetes is one of the most common NCDs. It is the fourth or fifth leading cause of death in most high-income countries and there is substantial evidence that it is an epidemic in many economicaly developing and newly industrialized nations. Complications from diabetes are resulting in increasing disability, reduced life expectancy and enormous health cost for virtually every society. 15 Therefore, early detection of individuals with prediabetes is of utter importance. Aims and objectives: The aim of the study was to determine the prevalence of risk factors for NCDs such as overweight and obesity, high risk waist circumference, hyperglycemia and high blood pressure among individuals, aged 45 and older, according to their sex, age, level of education. Vol. 2 No 1 (2011) Page 59

4 Methods/Study design: Research was conducted during 2003 and 2004 in the Autonomous Province of Vojvodina which is located in the northern part of the Republic of Serbia and has a population of (according to the 2002 Census) which makes 27,1% of the total population of Serbia. The sampling frame included the total population of AP Vojvodina of both sexes aged 45 and over, that is inhabitants according to the Census in The total sample consisted of individuals of both sexes, aged 45 and older, which makes 12.7% of the population of that age. A multi-stage stratified sampling was based on 2002 Census and the number of units was proportional to the number of inhabitants at three levels: district, municipality and settlement, also taking into account the urban and rural distribution. Based on a certain number of units for each settlement, sample units were selected as cluster samples consisting of households. The starting point for selection of households was the Central Office of a health center or dispensary/ambulance station. The study units were selected randomly, from all households with individuals aged 45 and older, until the number of examinees for the settlement was filled According to a unique principle, visiting nurses extended invitations to all citizens by a plan established in advance. The Institute of Public Health Novi Sad was the official coordinator of this research. The Ethics Committee of the Institute previously approved the research. The letters of invitation contained the following information: place and time of examination as well as short instructions for check-up. Visiting nurses also used this opportunity to point to the importance of following the provided instructions for examination. Inquiries and check-ups were performed in health centers (dispensaries or ambulance stations) or in local community offices. Depending on the number of examinees in each community, a team was created including a physician, a nurse and a medical laboratory technician. The study included gathering of the following data: general and demographic data, anthropometric measurements (body height [cm], body mass [kg], waist circumference [cm]) and calculated body mass index (BMI) [kg/m 2 ], values of systolic blood pressure and diastolic blood pressure [mmhg] and fasting glycemia [mmol/l]. Special questionnaire designed on the basis of well-established and highly regarded investigations and literature data was designed. 16 The general and demographic data were gathered using a questionnaire and an interview and included sex, age, educational attainment and type of settlement. Anthropometric characteristics were measured and interpreted in accordance with WHO Guidelines. 17,18 Body height was measured using a particularly mounted metal centimeter ruler. Subjects were standing on a flat surface, without shoes, heels together, Frankfurt plane horizontal, arms beside the body. They were asked to take a deep breath and stand upright. Then the triangle on the height ruler was slid down to the head, so that the hair was pressed flat. The height was measured to the nearest 0.1 cm. 17,18 Measurement of body mass was performed using a pre-calibrated decimal scale in kilograms. The examinee stood in the center of the scale platform, with heels together, and had to remove his/her shoes and heavy outer garments (jackets, coat, etc.). The weight was measured to the nearest 100 g. 17,18 BMI was calculated by WHO formula 18 using body mass and body height data. Waist circumference was measured using a plastic metric tape and reported in centimeters. It was measured from the position between lower rib margin and iliac crest with heels 25 to 30 cm apart. Measurement of waist circumference was performed in sitting position, and the tape was held firmly ensuring horizontal position. The waist circumference was measured to the nearest of 0.1 cm. 17,18 Blood pressure measurement was performed as recommended by WHO Guidelines 19 using a pre-calibrated mercury manometer in a sitting position. The results obtained were interpreted according to: Helsinki Group Recommendations from ,21 and The seventh revision of JNC 7 Report. 22 Capillary blood glucose testing was performed using a band test Medisense Precision Xtra (Abbott, USA). Fasting glycemia was determined 14 to 16 hours after the last meal. The obtained results were interpreted according to recommendations of WHO. 23 Vol. 2 No 1 (2011) Page 60

5 A special software was designed for data input which was performed by fully instructed operators who were informed about the objectives and content of the investigation, examinees and logical control. The obtained data was statistically processed using SPSS version 8.0. The statistical analysis was done using descriptive and differential statistics. Apart from the most current analyzing techniques for contingence tables, multivariate analysis was performed using logistic regression. A logistic model was used to determine the ODDS ratio for each risk factor and for the classification of risk factors for hyperglycemia and NCD development. Study limitations: Problems expected during the study were rejection to participate and insufficient response (especially in urban areas, because examinations were scheduled for early morning hours during working time). Solutions included continuous media coverage of the investigation. Employers were asked for understanding. The motivation of visiting nurses and members of medical teams were a key factor in carrying out the study, collecting data and achieving desired quality of data. Results/Discussion: Socio-demographic characteristics of the sample Out of individuals invited to participate in the study, were included in the sample, resulting in high response rate (70.7%). Socio-demographic characteristics of the sample are shown in Table 1. Table 1. Socio-demographic characteristics of the sample Women Men Total Charateristic [n] [%] [n] [%] [n] [%] Age, y Education level a Without or with partial elementary school Elementary school Secondary school College or university a χ² = , p<0.01 It is important to note that women and men have the same risks for developing NCDs until the menopause. Taking into account the age of the sampled individuals, most of the women from the sample are postmenopausal, naturaly having more risk factors for NCDs development. 12 The number of examinees increased with age. Over 40% of the sample included individuals of 65 years and older. The average age of the sample was 61.8 years. Vol. 2 No 1 (2011) Page 61

6 In regard to education, every third person from the sample aged 45 and over was without elementary education implying that high percentage of general population of APV has low-level education. In the group of people without education or with partial elementary school there were more women than men and the number increased with age. Every twelfth subject had a college or university degree. There were more men than women in this group of examinees (Table 1). In regard to the types of settlements, 47.6% of the sampled individuals lived in urban and 52.2% lived in rural settlements. Body mass index Body mass index was interpreted in accordance with WHO Expert Commitee Report. 18 Calculating of BMI showed that 74.3% of the examined population of the APV was overweight or obese, and that 33.3% was obese as shown in Table 2. More men were overweight and more women were obese, but The SuRF2 Report 24 noted a significant and upward trend of obesity and consequently the increase of BMI in men in Serbia. The highest prevalence of overweight was among women and men older than 60 years, but the number of overweight and obese significantly decreased among individuals of both sex older than 64 years, consistent with the results of the study of prevalence of overweight and obesity in the US states. 13 Table 2. BMI prevalence according to sex, age and education level BMI [kg/m 2 ] < Normal Obese class Underweight Overweight Obese class I Obese class II weight III Charateristic [n] [%] [n] [%] [n] [%] [n] [%] [n] [%] [n] [%] Woman a Age, y b Men a Age, y c Education level d Without or with partial elementary school Elementary Vol. 2 No 1 (2011) Page 62

7 school Secondary school College or university a χ² = , p < 0.01 b χ² = , p < 0.01 c χ² = , p < 0.01 d χ² = , p < Individuals with college or university degree were less likely to be obese than individuals with no elementary education or partial elementary education. Our findings correspond to the conclusions of previous studies 25,26 that the more educated groups (which often have higher incomes) have lower BMI values, possibly because their diets are based on grains, fruits and vegetables. Waist circumference Waist circumference was interpreted in accordance with WHO Expert Commitee Reports. 17,18 The obtained results showed that only one fifth of the examined population of AP Vojvodina had a desirable waist circumference (WC). Most examinees presented with high-risk, stage II WC. High-risk and stage II WC were more frequent in women, whereas stage I WC was more frequent in men (Table 3). Table 3. Waist circumference prevalence according to sex, age and education level WC Desirable WC High risk WC Stage I risk WC Stage II risk WC Charateristic [n] [%] [n] [%] [n] [%] [n] [%] Woman a Age, y b Men a Age, y c Education level d Without or with partial elementary school Elementary school Vol. 2 No 1 (2011) Page 63

8 Secondary school College or university a χ² = , p < 0.01 b χ² = , p < 0.01 c χ² = , p < 0.01 d χ² = , p < 0.01 High risk WC was the most frequent among men and women aged 45-49, and it decreased with age, though it increased in those aged 70 and over. The number of men and women with stage I WC increases up to the age of 69, the number of individuals with stage II WC increases up to the age of 64 (men) and 69 (women); after that the frequency of stage II WC decreases. Many metabolic investigations have shown that excess visceral adiposity (high risk WC) is a key feature of a phenomenon referred to as ectopic fat deposition, which has been associated with insulin resistence, atherogenic dislipidemia, hypertension, increased risk of thrombosis and inflammation. Hypertrophic adipocytes with large triglyceride stores will have a high lipolitic rate; they will produce more leptin and less adiponectin, and they are significantly related to circulating level of IL-6, TNF-α and CRP, increasing the risk of NCDs development, especially cardiovascular diseases. 27 The level of education affected values of waist circumference. A desirable waist circumference was more frequent among college and university graduates compared to those with lower levels of education. High risk and stage I high risk WC were more frequent among the population with higher education, while high risk, stage II WC was more frequent in the population with lower level of education, as expected; according to CDC, individuals with lower education attainment tend to make unhealthy food choices (high energy-dense nutrition) and lifestyle choices (insufficient physical activity), which frequently leads to visceral adiposity and increase in WC. 7,28,29 High WC is a proven risk factor associated with insulin resistence, prediabetes and type 2 diabetes, hypertension, metabolic syndrome and other NCDs. Blood pressure According to the Recommendations of Helsinki Commission from 2000, primary population parameters include prevalence of hypertension, which is defined as the total number of individuals with blood pressure 140/90 mmhg or higher, and those who take antihypertensive agents. The prevalence of individuals with normal blood pressure (BP) according to the Helsinki Commission was 46.5%, while 4.9% had borderline hypertension, and 48.7% had hypertension (Table 4). Analysis of hypertension prevalence using JNC 7 criteria implied that only 11.9% of the examined population of AP Vojvodina aged 45 and over had normal blood pressure. Hypertension was established in 65.6% of individuals as seen in Table 4. Individuals with or with partial elementary education were more likely to have hypertension than those with college or university degree. In the US, about 30% of the adults have hypertension (JNC 7 criteria) 22, making it the leading cause of death in the US. National Health Survey Serbia showed that hypertension presents the most significant burden for the population of Serbia and Vojvodina 10 affecting around half of the population. The differencies can be explained by more efficient primary prevention of CVD and other NCDs risks in the US than in Serbia and AP Vojvodina. Vol. 2 No 1 (2011) Page 64

9 Table 4. Blood pressure in accordance to sex, age and education level Helsinki Commission a JNC 7 b Stage I Stage II Normal BP Borderline BP Hypertension Normal Prehypertension hypertension hypertension Charateristic [n] [%] [n] [%] [n] [%] [n] [%] [n] [%] [n] [%] [n] [%] Woman Age, y b Men Age, y b Education level Without or with partial elementary school Elementary school Secondary school College or university a χ² = , p < 0.01 (women); χ²= , p < 0.01 (men) b χ² = , p < 0.01 (women); χ² = , p < 0.01 (men) Vol. 2 No 1 (2011) Page 65

10 Glycemia More than half of the representative APV population sample had normal glycemia. Diabetes was previously diagnosed by a physician in 7.7% examinees, whereas 2.7% of individuals were not aware of their disease. Hyperglycemia was more frequent among women and diabetes mellitus was more frequent among men. The number of individuals with fasting hyperglycemia and diabetes mellitus increased with age and among the eldest there were 37.1% of individuals with fasting hyperglycemia, and 15.2% with diabetes. This distribution in regard to glycemia and age of examinees was the same for men and women, except for the fact that in men aged 70 and over there was a slight decrease in prevalence of diabetes. Table 5. Glycemia in accordance to sex, age and education level Glycemia Fasting Normal glycemia Diabetes mellitus hyperglycemia Charateristic [n] [%] [n] [%] [n] [%] Woman Age, y a Men Age, y b Education level Without or with partial elementary school Elementary school Secondary school College or university a χ² = , p < 0.01 b χ²= , p < 0.01 Fasting hyperglycemia and diabetes mellitus were more frequent in individuals without or with partial elementary school, consistent with the findings from USA. 7 Prevalence of prediabetes in APV was about 30% which corresponds to International Diabetes Federation (IDF) global estimates. 15 Our results identified a group of individuals with prediabetes (impaired fasting glucose tolerance (IFG)) which is a taget for screening actions and other preventive activities for the decrease of type 2 diabetes prevalence and its complications, as well as reduction of DALYs, improvement of life quality and decrease in health care expenditure. 15 Vol. 2 No 1 (2011) Page 66

11 Prevalence of diabetes in AP Vojvodina was similar to the prevalence from USA research and with the prevalence of diabetes among middle-aged Chinese adults. 30 Association of diet-related risk factors for NCDs in APV In only 2.9% of the sampled individuals no diet-related risk factors for NCDs were detected. In the majority of the sampled population the association of three (35.4%) or four risk factors (38.9%) was present. Hypertension was the most prevalent risk factor among individuals with only one NCD risk factor present. The most common combinations of two risk factors were as follows: hypertension and age of 65 and older, high risk waist circumference and BMI 25 and hypertension and stage I and stage II high risk waist circumference, combined. Combinations of three risk factors were found among 35.4% of the sampled population of AP Vojvodina. Over 70% of the APV population has hypertension, stage I and II high risk waist circumference and BMI 25. All four risk factors were present in 38.9% of the inhabitants of AP Vojvodina (Table 6). Table 6. Risk factor clustering Characteristic [n] [%] No risk factors Single risk factor Hypertension Age BMI WC Two risk factors Hypertension + Age WC + BMI Hypertension + WC Hypertension + BMI WC + Age BMI + WC Three risk factors Hypertension + WC + BMI WC + Hypertension + Age WC + BMI + Age Hypertension + BMI + Age Four risk factors Hypertension was the most comon NCDs risk factor in the sample, and the most frequently detected risk factor among individuals with 2 or more risk factors, consistent with the National Health Survey Serbia results 10, making hypertension the most burdening disease in Serbia. Evidence suggest that there is an association between BMI and systolic BP, as well as between WC and systolic BP. 31 There is a growing body of evidence supporting the association between BMI and WC with BP, even suggesting that the link is becoming stronger over time. 31 Almost three quarters of APV population is affected by 3 risk factors in question (BMI, WC, BP) at the same time, raising further concern about the cardiovascular and cerebrovascular health in APV. Vol. 2 No 1 (2011) Page 67

12 Unifactorial analysis showed that neither of risk factors, regardless of the degree of statistical significance, can be considered as the only, unmistakable predictor of hyperglycemia, and joint presence of several risk factors was much more significant than any individual risk factor. After performing univariate analysis, multivariate logistic regression analysis was performed. In this kind of analysis, glycemia was the dependent dichotomic variable (0 = no hyperglycemia, 1 = with hyperglycemia) and independent dichotomic variables are: waist circumference, BMI, blood pressure, age (0 = no risk, 1 = at risk), just like in univariate analysis (Table 7). Table 7. Risk factors and their Odds Ratios for univariate and multivariate analysis Risk factors Univariate analysis Multivariate analysis Ranking based on ODDS (95%CI) ODDS (95%CI) multivariate analysis WC 2,006 (1,931-2,084) 1,536 (1,466-1,609) 1 BMI 1,740 (1,682-1,799) 1,345 (1,291-1,402) 3 Blood pressure 1,683 (1,608-1,762) 1,296 (1,235-1,360) 4 Age 1,581 (1,536-1,627) 1,497 (1,453-1,542) 2 Multivariate logistic regression analysis has shown that waist circumference is the most significant predictor of hyperglycemia. The second most significant predictor was age, the third was BMI and blood pressure was the worst predictor of hyperglycemia. Hyperglycemia was not directly affected by blood pressure, but elevated blood pressure is a consequence of obesity (especially abdominal obesity) resulting in WC increase. Univariate analysis also showed that waist circumference was the most significant predictor of hyperglycemia and the difference between univariate and multivariate analyses in regard to significance of these three risk factors (BMI, age, blood pressure) was the result of their association. Multivariate logistic regression analysis has shown that WC was the most significant predictor of hyperglycemia. The second most significant predictor was age, the third BMI and blood pressure was shown to be the least significant predictor of hyperglycemia. Conclusion: WHO states that NCDs are the leading cause of death in the world, but the key message from WHO, CDC and many wealthy countries is that it is possible to delay death from NCD by several decades, therby avoiding death among middle-aged people. Aging of the world population, especially in developing countries results in a growing number of people over 70 whose risks of NCDs development are far greater than among younger adults. Our research showed that in AP Vojvodina, older people frequently have multiple NCD risk factors, with the number of coincidentaly present risk factors increasing with age. Assessment of risk factors for NCDs is a prerequisite for successful interventions in the middle and older age that give short-term and long-term health and financial benefits. According to WHO recommendations, every country shoud determine and follow up risk factors that are relevant for that specific country. With the knowledge that cardiovascular diseases present the biggest burden for Serbian and APV society, in our research we determined the prevalence and the of risk factors for CVD: overweight, obesity, waist circumference, hypertension (both risk factor and NCD itself) and glycemia (both risk factor and NCD itself) in relation to age, sex and educational attainment. Prevalence of the determined risk factors is found to be similar to the prevalence in other developing countries and estimates of WHO and CDC. Using these results, the Secretary of Health of AP Vojvodina can plan preventive and treatment actions for NCDs in Vojvodina as a whole, as well as in local municipalities since the prevalence of NCD risk factors for every municipality was determined. Vol. 2 No 1 (2011) Page 68

13 Acknowledgements: The study was financed by Secretariat of Health and Social Policy Executive Council AP Vojvodina and conducted by Institute of Public Health Novi Sad as a part of Faculty of Medicine (University of Novi Sad). Prof. Budimka Novaković was the leading researcher. All participating parties, including physicians and nurses working on the terrain participated in the study by their own will and without financial, or any other benefit. Abbreviations: NCDs non-communicable diseases WHO World Health Organization DALYs Disability-adjusted life years CDC Centers for Disease Control and Prevention APV Autonomous Province of Vojvodina BMI Body Mass Index BP Blood Pressure JNC 7 - The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure WC Waist circumference IDF International Diabetes Federation References: 1. World Health Organization. The World Health Report Geneva, Switzerland: World Health Organization; Report of a Joint WHO/FAO Expert Consultation. Diet, Nutrition and the Prevention of Chronic Disease. Geneva, Switzerland: World Health Organization; (WHO Tehnical Report Series, No 916) 3. World Health Organization. Global Health Risk. Mortality and Burden of Diseases Attributable to Selected Major Risks. Geneva, Switzerland: World Health Organization: Cylus J, Hartman M, Washington B, et al. Pronounced gender and age differencies are evident in personal health care spending per person. [Published online ahead of print Decmber 2010] Health Affairs Accessed December 9, 2010 (doi: /hlthaff ) 5. World Health Organization. International Agency for Research on Cancer. World cancer report. Lyon, France: International Agency for Research on Cancer; Tsigos C, Hainer V, Basdevant A, et al. Management of obesity in adults: European clinical practice guidelines. Obesity Facts. 2008;1: Mackay J, Mensah GA. The Atlas of Heart Disease and Stroke. Geneva, Switzerland: World Health Organization; World Health Organization. Preventing Chronic Diseases. Geneva, Switzerland: World Health Organization; Vol. 2 No 1 (2011) Page 69

14 9. Trajković-Pavlović LJ, Novaković B, Popović M, et al. Nutrition in Rural Areas: a Focus on Serbia and Montenegro. Second Conference on Rural Health & First International Conference on Occupational and Einviromental Health in Mediterranean, South East and Central European Countries, Belgrade, Book of Abstracts, p National Health Survey Serbia. Belgrade, Serbia: Ministry of health, Republic of Serbia; Ezzati M, Lopez AD, Rodgers A, et al. Selected Major Risk Factors and Global and Regional Burden of Disease. Lancet. 2002;360: Vital Signs: State-specific Obesity Prevalence Among Adults United States, MMWR Aug;59. (Early Release) 13. Pischon T, Boeing H, Hoffmann K, et al. General and Abdominal Adiposity and Risk of Death in Europe. N Engl J Med. 2008;359: World Health Organization. Definition and Diagnostic of Diabetes Mellitus and Intermediate Hyperglycaemia. Report of a WHO/IDF consultation. Geneva, Switzerland: WHO; IDF Diabetes Atlas. 4th ed. Brussel, Belgium: Internation Diabetes Federation; American Diabetic Association. Posititon Statement. Screening for diabetes. Diabetes Care. 2002;25(Suppl):S21-S Report of WHO Expert Committee. Physical Status: the Use and Interpretation of Anthropometry. Geneva, Switzerland: World Health Organization; (WHO Technical Report Series, No 854) 18. Report of WHO Consultation. Obesity: preventing and managing the global epidemic. Geneva, Switzerland: World Health Organization; (WHO Technical Report Series, No. 894) 19. Report of a WHO expert committee on Hypertension Control. Hypertension control. Geneva, Switzerland: World Health Organization; (WHO technical report series; No 862) 20. Wolf Maier K, Cooper RS, Banegas JR, et al. Hypertension Prevalence and Blood Pressure Levels in 6 European Countries, Canada, and the United States. JAMA. 2003;289(18): Wolf HK, Tuomilehto J, Kuulasmaa K, at al. Blood pressure in the 41 populations of the WHO MONICA Project. J Hum Hypertens. 1997;11: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC7 Report. JAMA. 2002;289(19): World Health Organization. Definition, Diagnosis and Clasiffication of Diabetes Mellitus and its Complications. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva, Switzerland: World Health Organization; World Health Organization. Surveillance of Chronic Disease: Risk Factors: Country-level Data and Comparable Estimates.The SuRF2 Report. Geneva, Switzerland: World Health Organization; Popkin BM. The Nutrition Transitioning: Low income Countries: an Emerging Crisis. Nutr Rev. 1995;52: Drewnowski A, Popkin BM. The Nutrition Transition: New Trends in the Global Diet. Nutr Rev. 1997;55(2): Vol. 2 No 1 (2011) Page 70

15 27. Mathieu P, Lemieux I, Després JP. Obesity, Inflammation and Cardiovascular Risk. Clin Pharmacol Therapeut. 2010;87(4): McKeigue PM, Marmot MG. Mortality From Coronary Heart Disease in Asian Communities in London. Lancet. 1985;2: McKeigue PM, Miller GJ, Marmot MG. Coronary Heart Disease in South Asians: a Review. J Clin Epidemiol. 1989;42: Liu S, Wang W, Zhang J, et al. Prevalence of Diabetes and Impaired Fasting Glucose in Chinese Adults, China National Nutrition and Health Survey, Prev Chronic Dis. 2011;8(1). 31. Tu Y-K, Summers LKM, Burley V, et al. Trends in the Association Between Blood Pressure and Obesity in a Taiwanese Population Between 1996 and J Hum Hypertens Published ahead of print, online 25 March Vol. 2 No 1 (2011) Page 71