The purpose of this study was to examine the prevalence of the metabolic syndrome and its components among residents of a small town in Russia. A descriptive design was used to examine the metabolic syndrome and its components among a convenience sample of adults aged >= 18 years. Health assessments and screenings were conducted in a rural health clinic in southern Russia. Data on blood pressure, fasting glucose, HDL cholesterol, triglyceride cholesterol and central obesity were collected, as well as demographic, health history and lifestyle information. 147 persons chose to participate. The majority of participants were female and 92% were >= 47 years of age. Many persons suffered from three or more metabolic syndrome components, with hypertension the most common metabolic syndrome component. In conclusion, patients at the clinic were at risk for developing cardiac disease. Health screening and health education for cardiovascular and diabetes risk is needed to assist this population in decreasing their metabolic syndrome and its consequential effects.
As a major cause of death and disability, cardiovascular disease is a worldwide health priority. Many countries struggle with screening, treatment and consequences in dollars and quality of life. Many of the risk factors and consequences of cardiovascular disease are now considered a syndrome, called the metabolic syndrome.1–3 Not only is the presence of the metabolic syndrome and its components an indicator of cardiovascular health, it is also being used as an indicator of developing diabetes.4,5 Thus, two major health issues might be prevented and more accurately diagnosed through screening for the metabolic syndrome and its components (see Table 1). In this paper, we present an examination of the metabolic syndrome and its components in a sample of Russian citizens. The study was conducted by faculty members, graduate and undergraduate students during an international service-learning experience through a school of nursing located in the south-east USA.
Table 1 Metabolic syndrome components
Lifestyle and behaviour patterns such as obesity, decreased physical activity, poor nutrition and lack of adequate primary health care are common in Russian population. The International Diabetes Federation (2003) and the International Obesity Task Force (2005) note that Russia is one of the top 10 countries in terms of diabetes prevalence.6,7 In 2001, a needs assessment conducted in Kuzmolovsky found that the leading cause of death was cardiovascular disease followed by malignant neoplasms and cerebrovascular disease.8,9 Life expectancy for persons in Russia is similar to that in developing countries. For men, life expectancy is 58 years and for women 71 years. The death rate is 12.2 per 1000 population. In the 1990s, the death rate for cardiovascular heart disease was 172.1 per 100 000 population, which compares with 86.4 per 100 000 in Western Europe; the death rate for ischaemic heart disease was 93.39 per 100 000, compared with 41.4 per 100 000 for Western Europe; and, the death rate for cerebrovascular disease was 50.2 per 100 000 compared with 17.74 per 100 000 for Western Europe.10–13 Expenditures for health care in Russia are approximately 2–3% of the GNP, which is far lower than that in developed countries in Western Europe, Asia or North America.14–17 The project was to examine the prevalence of the metabolic syndrome among the population of Kuzmolovsky, Russia, aged >= 18 years who attended the Kuzmolovsky Healthcare Clinic. The clinic serves a population of 10 480 persons. During April 2004, a group of School of Nursing faculty and students lived for 2 weeks in Kuzmolovsky. They did laboratory testing, collected demographic and health information, and offered classes on the core components of the metabolic syndrome and associated comorbidities. These activities were seen as a first step towards improving the health behaviours of the patients of the Kuzmolovsky Healthcare Clinic so as to decrease complications from cardiovascular disease.
A descriptive design was used to conduct an examination of the metabolic syndrome and its components among adults in Kuzmolovsky, Russia. Kuzmolovsky is a rural community with a population of 9620 in the northern part of Russia, close to St. Petersburg. There is only one clinic in Kuzmolovsky that serves the population of that city plus the rural towns of Kuzmolovo, Kualovo, Audio, Vapkolovo and Mictolovo, for an additional population of 1112. In 2004, the Kuzmolovsky Healthcare Clinic served 12 273 persons.18 The clinic staff includes 18 physicians, 20 nurses, 5 medical records staff and 8 sanitation workers. Clinic services include internal medicine, orthopaedics, paediatrics, gynaecology, tuberculosis, narcology (alcohol and drug abuse) and dentistry. There are no laboratory facilities and all laboratory work is drawn at the hospital in the adjacent town. The clinic does offer affordable medications such as antibiotics, medications for hypertension and diabetes and others for common diseases. Cholesterol-reducing agents are less widely available but can be ordered. Most of these medications are bought from pharmaceutical companies from Eastern Europe and India. The leading causes of death in Kuzmolovsky are cardiovascular disease, followed by malignant neoplasms and cerebrovascular disease.10 In 2001, there were 60 deaths from heart disease, 35 from cerebrovascular disease, 26 from arteriosclerosis and 2 from diabetes.18 Recruitment of subjects was through the use of flyers in Russian posted in the community and by employees of the clinic in the lobby. The flyers contained basic information about the study and informed persons that they must fast after midnight to participate in the study.
A comprehensive data survey was designed to measure demographic variables and to obtain a brief health history and personal knowledge of health behaviours. Basic demographic questions such as age, marital status, education and questions related to health history and personal knowledge of health behaviours were used. Health history questions centred on coronary disease and diabetes risks including diagnosis or family history of hyperlipidaemia, hypertension, diabetes, a previous myocardial infarction or a stroke, and medication usage. Personal knowledge of health behaviours centred on exercise, nutritional intake, sleep, and tobacco and alcohol use. Specifically, participants were also asked whether they had elevated blood sugar and, if so, whether they were taking medications for the condition. The survey was developed in English, translated into Russian and back-translated into English for conceptual congruence. The form consisted of 30 questions and took [almost equal to]30 min to complete.
Once subjects arrived at the clinic, they were given written consent forms to complete. Subjects were informed that their participation was voluntary and that they could refuse to participate in the study at any time without consequences to their care provided at the clinic. They were then asked whether they had been fasting since midnight. Persons who had been fasting proceeded to complete the demographic survey. Persons who had not been fasting were asked to return the next day if they wanted to participate in the study.
When participants completed the survey, they were taken to a clinic room where supervised and trained nursing students obtained their blood pressure, height, weight and abdominal circumference. Standard clinical procedures were used to obtain systolic and diastolic blood pressure measurements with a sphygmomanometer in a sitting position. Central obesity was measured with a standard Gantt tape measure at the waist with clothes removed while subjects were standing.19,20 Once that measure was completed, nursing students obtained fasting total cholesterol with high-density lipoprotein (HDL) and low-density lipoprotein (LDL), triglycerides and glucose using sterile technique extracting finger stick blood with a lancet. Blood droplets were placed on a laboratory machine module platform in the Cholestech LDX machines(CA, USA). Subjects with glucose levels > 200 had their blood drawn via finger stick and checked using a haemoglobin A1C machine(CA, USA) for levels within the past 3 months. Accuracy and precision of the Cholestech LDX and GDX profiles are comparable to those obtained by reference methods used routinely in clinical diagnostic laboratories.21–28 Laboratory results were collected in mmol/L, which is the European standard, and then calculated to the US standard of mg/dL. Determinants of risk and cut-off scores for the metabolic syndrome and its components published by the National Heart, Lung, and Blood Institute and The National Cholesterol Education Program were used for risk assessment.2
A Russian physician, who is primarily a medical researcher close to St. Petersburg, acted as the interpreter for information exchanged between the researchers and clinic physicians and participants. All subjects received a physical by an American nurse practitioner with the help of the Russian interpreter. A health assessment, test screening results and appropriate health education information was shared with subjects and clinic staff. Additionally, for humanitarian and ethical reasons, each afternoon nursing students conducted health education at the clinic on topics such as nutrition, cardiovascular health risks and diabetes with the interpreter. American researchers and the Russian interpreter reviewed all teaching projects for cultural congruence.
Using SPSS 11.5 (SPSS, Chicago, IL, USA), the researchers used frequency distributions, means and standard deviations, as appropriate, to characterize the sample on the basis of demographic variables and metabolic syndrome markers. Calculations were used to transform units from mm/L to mg/dL using formulas for appropriate physiological measures. To determine the prevalence of metabolic syndrome and it components, percentages of metabolic syndrome total and metabolic syndrome components in the clinic population were calculated. Chi-square analysis (dichotomous) and phi correlations (interval and dichotomous) were used to assess how predisposing factors differentiate those with metabolic syndrome and its components. Multiple linear regressions with independent variables (age, gender, body mass index (BMI), systolic blood pressure, diastolic blood pressure, total cholesterol and LDL cholesterol) and one dependent variable (level of the metabolic syndrome or one of its markers) were used to determine the impact of predisposing on the level of the metabolic syndrome and its components. Variables were removed as an independent variable or when there were collinearity concerns (HDL equation). Five linear regressions were computed. The equation F statistic was examined for statistical significance and, if significant, unstandardized parameter estimates were examined for individual significance. One logistic regression equation was computed, for the dependent variable of having a Metabolic Syndrome (MS) hypertension risk. The model chi-square was examined for statistical significance and, if significant, each variable was examined for individual significance. Alpha level was set at 0.05 for all tests. Nquery Advisor determined that a minimum sample size of n = 48 would achieve 80% power at [alpha] = 0.05 using multiple linear regression to detect an overall R2 of 0.25 with six independent variables in research question 3, the most complex question. The institutional review board of the University of North Carolina at Greensboro and the Kuzmolovsky Healthcare Clinic Senior Administrator granted approval for the study. The study conforms to the provisions of the Declaration of Helsinki, 1995, 2000.
A sample of 146 subjects was used in the data analysis. The majority of the sample (91%) was women. Ages ranged from 25 to 89 years with a mean age of 67.65 (SD = 10.5) years. Almost half of the participants were married (44%) and most of them had lived in Kuzmolovsky >= 12 years. The great majority of participants (90%) said they had heart disease, and 86% had hypertension. Of those with self-reported hypertension, most (85%) were taking hypertensive medications. Only eight subjects were taking cholesterol medications. However, laboratory screenings indicated a larger number of participants had cholesterol levels > 200 (see Table 2). In fact, total cholesterol averaged 231.13 (SD = 45.23) with 339 the highest value. All but one had LDL within the optimal range. BMI averaged 29.5 (SD = 5.52) and 44.16 was the highest value. Importantly, 29% had experienced a >= 5 kg weight gain in the past 6 months. Thirty-one per cent of the sample met recommended activity levels of at least three times per week. Additional health history indicated 15 participants had been diagnosed with a heart attack, eight had suffered a previous stroke, six persons had an alcoholic drink daily and one person smoked at least one pack of cigarettes per day.
Table 2 Body mass index and total cholesterol levels (n = 146)
Each of the five metabolic syndrome components was present in this Russian population. Of the participants who completed physical measurements, two persons did not have any risk factors or components for the metabolic syndrome or coronary heart disease. Specific prevalence for each metabolic syndrome component is also alarming (see Table 3). Over three-quarters had HDL risk and one-third had triglyceride risk. Sixty per cent had elevated fasting glucose and high blood pressure. A large number and proportion of participants had waist circumference measurements that exceeded healthy recommendations. Two-thirds of the participants were found to have three or more components and thus suffered from the metabolic syndrome (see Table 4).
Table 3 Prevalence of metabolic syndrome components (n = 146)
Table 4 Participants with components for the metabolic syndrome (n = 146)
Several demographic variables and risk factors differentiate those with MS and its components from those without the syndrome or component risk. Age, gender, BMI, total cholesterol, meeting recommended activity level, diastolic hypertension and systolic hypertension and glucose level were the independent variables. Metabolic syndrome presence and risk for each component served as outcomes in the chi-square and correlational analyses.
Predisposing demographic variables differentiated the presence of metabolic syndrome and selected components. Phi correlations indicated older age was related to waist circumference risk (r = 0.18, P < class="fulltext-SP">2 = 15.52, P < class="fulltext-SP">2 = 10.48, P <>
Predisposing risk factors were less differentiating. Meeting activity recommendations and total cholesterol risk was not related to any MS risk component, nor the presence of MS. BMI overweight condition was related to the presence of MS ([chi]2 = 11.67, P < class="fulltext-SP">2 = 8.16, P < class="fulltext-SP">2 = 39.70, P < class="fulltext-SP">2 = 6.89, P <>
Predisposing demographic variables and risk factors predicted the total number of components of the metabolic syndrome experienced and the severity of each one. The total number of metabolic syndrome components experienced was significantly impacted by female gender, higher BMI, higher total cholesterol and lower LDL cholesterol (F = 9.213, P <>
Triglyceride level (mg/dL) was impacted primarily by higher total cholesterol and lower LDL cholesterol (F = 5.407, P <>
In the HDL regression equation, LDL cholesterol was omitted because that predisposing risk factor was perfectly correlated with the outcome variable. With consideration of the remaining seven factors, HDL cholesterol levels (mg/dL) were impacted by lower BMI and higher total cholesterol levels (F = 3.23, P <>
Waist circumference (cm) was significantly impacted by older age, higher BMI and less activity (F = 28.85, P <>
As MS hypertension (>=130/85) risk was experienced by 63.7% of the sample and is binary, logistic regression was first used to determine predisposing factors impacting the risk, with diastolic blood pressure omitted because of high correlation with the outcome variable. Results indicated that higher BMI, total cholesterol and systolic blood pressure were predictive of the MS hypertension risk ([chi]2 = 51.25, d.f. 7, P < class="fulltext-IT">R2 = 0.561) by predisposing variables. When systolic blood pressure was removed from the equation, higher BMI and total cholesterol remained the predictors ([chi]2 = 18.57, d.f. 6, P < class="fulltext-IT">R2 = 0.234).
To more fully determine the level of risk for hypertension, each subcomponent (diastolic and systolic blood pressure) was used as the dependent variable in linear regression. Although the amount of variance accounted for by predisposing variables approached 50%, the correlation between systolic and diastolic blood pressure was 0.68. For conceptual clarity, we omitted the subcomponents from the equations. Results then indicated that systolic blood pressure was impacted by older age and higher BMI (F = 3.24, P < class="fulltext-IT">F = 3.44, P <>
The majority of the Russians were at significant risk for developing coronary artery disease. This finding is consistent with World Health Reports from the region and from the World Health Organization.17,29 Few participants acknowledged that they had elevated cholesterol; cholesterol measurement showed that the majority did indeed have elevated cholesterol levels, with abnormally low HDL and abnormally high triglycerides, indicating elevated risk for heart disease. Most participants were aware that they had elevated blood pressure and were overweight. Further, the majority who had elevated blood pressures were currently taking antihypertensive medications. However, the blood pressure readings of the participants were still elevated. Few participants said they had elevated cholesterol or glucose or were taking medications for these conditions. This is most likely due to the fact that laboratory testing for any illness or diagnosis is rare in rural Russia. Providers at the Kuzmolovsky Healthcare Clinic urged their patients to take advantage of this screening opportunity, so much so that participants waited in line outside in the cold. The results were given to clinic providers so that they could recommend treatment. Medication therapies from Eastern European and Indian companies were available although clinic providers pointed out that cholesterol-lowering medications were not as easily obtained.
Nursing students with an interpreter held educational sessions each afternoon. The discussions included information on nutrition and exercise.30 Interestingly, not everyone in Kuzmolovsky has access to a personal automobile, so many people walk a great deal. Elevators are not provided in older buildings and people are accustomed to climbing stairs. Further, people are used to shopping daily for meal preparation. Nevertheless, the majority of these participants were overweight. This is most likely due to the types of foods eaten, with high calories from carbohydrates and dairy products. Fortunately, the majority of participants, although mostly older women, did not smoke or use alcohol.
Nursing students found the integrated service learning research project both challenging and rewarding. The students prepared their educational materials in advance, and learned how to operate the Cholestech laboratory equipment and how to interpret the results.
During this study, researchers carefully considered the implications of their research on the rural Russian population. Researchers were there as invited guests of the Kuzmolovsky Healthcare Clinic physicians. The researchers judiciously chose a Russian physician to act as interpreter. It was known in advance that medications would be available to participants even if difficult to obtain. Hopefully, knowledge of laboratory findings will aid in participants making important lifestyle changes. These considerations were based on the world renowned Nuffield Council on Bioethics (2005) international guides for conducting public health research in developing countries. In reports published in 2002 with a follow up in 2005, they indicated that special consideration should be used when western researchers recommend treatments that are not readily available in developing countries.31
At the end of the project, the Kuzmolovsky Healthcare Clinic staff were appreciative of the services provided and requested a return visit with more laboratory supplies for screening. Goals for a future experience include attracting more male and younger participants and providing increased education on the value of controlling hypertension. Faculty and students are looking forward to their next experience.
Partial funding was received from The University of North Carolina at Greensboro (UNCG) Associate Provost for Research Faculty Research Award 2003– 4 and the Gamma Zeta Chapter of Sigma Theta Tau International Ruth B. Council Award 2003– 4.
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Key words: cardiovascular; health promotion; international health; policy; quantitative
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