Risk Factors for Coronary Heart Disease Among Lebanese Women: A Case–Control Study

Figures & data

Figure 1 Flowchart of women included in the study.

Table 1 Baseline Socio-Demographic Characteristics of Study Population

Characteristics	Pre-Menopausal Women n (%)			Post-Menopausal Women n (%)
	192 (12.8%)			1308 (87.2%)
Total Patients: 1500	Controls	Cases	P-value	Controls	Cases	P-value
	174 (90.6%)	18 (9.4%)		1026 (78.4%)	282 (21.6%)
Age (years)	44.48 ± 3.82	46.44 ± 4.27	0.047*	65.39 ± 10.73	66.68 ± 9.38	0.049*
Place of residence			0.297			0.020*
Beirut	36 (20.7%)	5 (27.8%)		231 (22.5%)	79 (28.0%)
Mount Lebanon	79 (45.4%)	6 (33.3%)		500 (48.7%)	108 (38.3%)
South Lebanon/Nabatieh	12 (6.9%)	1 (5.6%)		77 (7.5%)	21 (7.4%)
North/ Akkar	21 (12.1%)	5 (27.8%)		121 (11.8%)	36 (12.8%)
Bekaa/Baalback/Hermel	26 (14.9%)	1 (5.6%)		97 (9.5%)	38 (13.5%)
Type of living area			0.576			0.238
Urban	45 (25.9%)	6 (33.3%)		301 (29.3%)	93 (33.0%)
Rural/peri-urban	129 (74.1%)	12 (66.7%)		725 (70.7%)	189 (67.0%)
Marital status			0.221			0.118
Married	135 (77.6%)	17 (94.4%)		540 (52.6%)	132 (46.8%)
Divorced/widowed	16 (9.2%)	1 (5.6%)		432 (42.1%)	138 (48.9%)
Single	23 (13.2%)	0		54 (5.3%)	12 (4.3%)
Working status			0.784			0.489
In professional activity	49 (28.2%)	4 (22.2%)		74 (7.2%)	17 (6.0%)
Unemployed/ Retired	125 (71.8%)	14 (77.8%)		952 (92.8%)	265 (94.0%)
Educational level			0.198			0.115
Illiterate/or primary school level	23 (13.2%)	5 (27.8%)		418 (40.7%)	137 (48.6%)
Complementary school level	59 (33.9%)	4 (22.2%)		386 (37.6%)	96 (34.0%)
Secondary school level	40 (23.0%)	6 (33.3%)		125 (12.2%)	28 (9.9%)
University	52 (29.9%)	3 (16.7%)		97 (9.5%)	21 (7.4%)
Monthly income of the women’s family			0.582			0.143
< 500,000 LBP	11 (6.3%)	1 (5.6%)		214 (20.9%)	56 (19.9%)
500,000–1,000,000 LBP	22 (12.6%)	1 (5.6%)		195 (19.0%)	54 (19.1%)
1,000,000–2,000,000 LBP	83 (47.7%)	7 (38.9%)		373 (36.4%)	106 (37.6%)
2,000,000–4,000,0000 LBP	53 (30.5%)	9 (50.0%)		202 (19.7%)	63 (22.3%)
> 4,000,000 LBP	5 (2.9%)	0		42 (4.1%)	3 (1.1%)
Monthly income per individual			0.608			0.129
Low (<180,000 LBP/month/person)	14 (8.0%)	1 (5.6%)		33 (3.2%)	16 (5.7%)
Middle (180,000–675,000 LBP/month/person)	120 (69.0%)	11 (61.1%)		732 (71.3%)	191 (67.7%)
High (>675,000 LBP/month/person)	40 (23.0%)	6 (33.3%)		261 (25.4%)	75 (26.6%)

Notes: Data are presented as count (%). *P <0.05 was considered significant.

Abbreviation: LBP, Lebanese pounds.

Table 2 Differences in Lifestyle and Individual Risk Factors According to Studied Women Status

Characteristics		Pre-Menopausal Women n (%)						Post-Menopausal Women n (%)
		192 (12.8%)						1308 (87.2%)
		Controls	Cases	OR (95% CI)		P-value		Controls	Cases	OR (95% CI)	P-value
		174 (90.6%)	18 (9.4%)					1026 (78.4%)	282 (21.6%)
BMI (mean ± SD)		29.32 ± 6.67	29.53 ± 5.40	1.005 (0.934–1.081)		0.896		29.70 ± 6.68	29.62 ± 5.86	0.998 (0.978–1.019)	0.868
Smoking status (cigarette/or waterpipe)
Non-smoker		80 (46.0%)	4 (22.2%)	1.00 (Ref.)		–		542 (52.8%)	112 (39.7%)	1.00 (Ref.)	–
Active smoking history		2 (1.1%)	0	–		0.999		77 (7.5%)	20 (7.1%)	1.257 (0.738–2.140)	0.400
Current active smoker		92 (52.9%)	14 (77.8%)	3.043 (0.963–9.620)		0.058		407 (39.7%)	150 (53.2%)	1.784 (1.353–2.352)	<0.001*
Previous smoking status
Never		80 (46.0%)	4 (22.2%)	1.00 (Ref.)		–		542 (52.8%)	112 (39.7%)	1.00 (Ref.)	–
Cigarette		0	0	–		–		55 (5.4%)	15 (5.3%)	1.320 (0.720–2.419)	0.370
Waterpipe		3 (1.7%)	0	–		0.999		26 (2.5%)	2 (0.7%)	1.936 (1.445–2.593)	<0.001*
Mixed smoking		0	0	–		–		6 (0.6%)	4 (1.4%)	1.452 (0.393–5.360)	0.576
Current smoking status
Never		80 (46.0%)	4 (22.2%)	1.00 (Ref.)		–		542 (52.8%)	112 (39.7%)	1.00 (Ref.)	–
Cigarette		41 (23.6%)	10 (55.6%)	4.878 (1.441–16.508)		0.011*		308 (30.0%)	122 (43.3%)	1.917 (1.431–2.567)	<0.001*
Waterpipe		48 (27.6%)	3 (16.7%)	1.250 (0.268–5.826)		0.776		89 (8.7%)	25 (8.9%)	1.359 (0.834–2.215)	0.218
Mixed smoking		3 (1.7%)	1 (5.6%)	6.667 (0.561–79.287)		0.133		10 (1.0%)	3 (1.1%)	1.452 (0.393–5.360)	0.576
Total cigarette smoking, quantification (for previous and current smokers)
Non smoker		130 (74.7%)	7 (38.9%)	1.00 (Ref.)		–		647 (63.1%)	138 (48.9%)	1.00 (Ref.)	–
Up to 20 pack-years		23 (13.2%)	4 (22.2%)	3.230 (0.875–11.923)		0.078		125 (12.2%)	28 (9.9%)	1.050 (0.670–1.646)	0.831
More than 20 up to 40 pack-years		16 (9.2%)	2 (11.1%)	2.321 (0.444–12.149)		0.319		122 (11.9%)	44 (15.6%)	1.691 (1.144–2.499)	0.008*
More than 40 pack-years		5 (2.9%)	5 (27.8%)	18.571 (4.338–79.511)		<0.001*		132 (12.9%)	72 (25.5%)	2.557 (1.819–3.596)	<0.001*
Total waterpipe smoking, quantification (for previous and current smokers)
Non smoker		120 (69.0%)	14 (77.8%)	1.00 (Ref.)		–		895 (87.2%)	248 (87.9%)	1.00 (Ref.)
Up to 30 waterpipes-years		16 (9.2%)	2 (11.1%)	1.071 (0.223–5.154)		0.931		25 (2.4%)	3 (1.1%)	0.433 (0.130–1.446)	0.174
More than 30 waterpipes-years		38 (21.8%)	2 (11.1%)	0.451 (0.098–2.075)		0.307		106 (10.3%)	31 (11.0%)	1.055 (0.691–1.613)	0.803
Hypertension
No		122 (70.1%)	3 (16.7%)	1.00 (Ref.)		–		257 (25.0%)	23 (8.2%)	1.00 (Ref.)	–
Yes		52 (29.9%)	15 (83.3%)	11.731 (3.257–42.250)		<0.001*		769 (75.0%)	259 (91.8%)	3.763 (2.402–5.898)	<0.001*
Diabetes
No		147 (84.5%)	11 (61.1%)	1.00 (Ref.)		–		615 (59.9%)	127 (45.0%)	1.00 (Ref.)	–
Yes		27 (15.5%)	7 (38.9%)	3.465 (1.234–9.731)		0.018*		411 (40.1%)	155 (55.0%)	1.826 (1.400–2.382)	<0.001*
Dyslipidemia
No		136 (78.2%)	4 (22.2%)	1.00 (Ref.)		–		480 (46.8%)	62 (22.0%)	1.00 (Ref.)	–
Yes		38 (21.8%)	14 (77.8%)	12.526 (3.896–40.277)		<0.001*		546 (53.2%)	220 (78.0%)	3.119 (2.294–4.242)	<0.001*
Declared joint pain
No		93 (53.4%)	5 (27.8%)	1.00 (Ref.)		–		432 (42.1%)	85 (30.1%)	1.00 (Ref.)	–
Yes		81 (46.6%)	13 (72.2%)	2.985 (1.020–8.734)		0.046*		594 (57.9%)	197 (69.9%)	1.686 (1.270–2.237)	<0.001*
Rheumatic diseases
No		170 (97.7%)	18 (100.0%)	1.00 (Ref.)		–		972 (94.7%)	270 (95.7%)	1.00 (Ref.)	–
Yes		4 (2.3%)	0	–		0.999		54 (5.3%)	12 (4.3%)	0.800 (0.422–1.517)	0.494
Periodontitis
No		144 (82.8%)	14 (77.8%)	1.00 (Ref.)		–		841 (82.0%)	223 (79.1%)	1.00 (Ref.)	–
Yes		30 (17.2%)	4 (22.2%)	1.371 (0.422–4.458)		0.599		185 (18.0%)	59 (20.9%)	1.203 (0.866–1.670)	0.270
Family history of
- Premature CHD
No		142 (81.6%)	7 (38.9%)	1.00 (Ref.)		–		861 (83.9%)	184 (65.2%)	1.00 (Ref.)	–
Yes		32 (18.4%)	11 (61.1%)	6.973 (2.509–19.383)		<0.001*		165 (16.1%)	98 (34.8%)	2.779 (2.066–3.738)	<0.001*
- Stroke
No		173 (99.4%)	18 (100.0%)	1.00 (Ref.)		–		1016 (99.0%)	277 (98.2%)	1.00 (Ref.)	–
Yes		1 (0.6%)	0	–		1.00		10 (1.0%)	5 (1.8%)	1.834 (0.622–5.410)	0.272
- Hypertension
No		103 (59.2%)	8 (44.4%)	1.00 (Ref.)		–		624 (60.8%)	152 (53.9%)	1.00 (Ref.)	–
Yes		71 (40.8%)	10 (55.6%)	1.813 (0.682–4.820)		0.233		402 (39.2%)	130 (46.1%)	1.328 (1.018–1.731)	0.037*
- Diabetes
No		98 (56.3%)	9 (50.0%)	1.00 (Ref.)		–		627 (61.1%)	167 (59.2%)	1.00 (Ref.)	–
Yes		76 (43.7%)	9 (50.0%)	1.289 (0.488–3.406)		0.608		399 (38.9%)	115 (40.8%)	1.082 (0.827–1.416)	0.565
- Dyslipidemia
No		153 (87.9%)	10 (55.6%)	1.00 (Ref.)		–		936 (91.2%)	254 (90.1%)	1.00 (Ref.)	–
Yes		21 (12.1%)	8 (44.4%)	5.829 (2.069–16.417)		0.001*		90 (8.8%)	28 (9.9%)	1.146 (0.734–1.791)	0.548

Notes: Data are presented as count (%) or mean ± standard deviation (SD). *P <0.05 was considered significant.

Abbreviations: OR, odds ratio; CI, confidence interval; BMI, body mass index; CHD, coronary heart disease.

Table 3 Difference in Various Environmental and Behavioral Risk Factors According to Studied Women Status

Scores	Cronbach’s Alpha	Pre-Menopausal Women n (%)				Post-Menopausal Women n (%)
		192 (12.8%)				1308 (87.2%)
		Controls	Cases	OR (95% CI)	P-value	Controls	Cases	OR (95% CI)	P-value
		174 (90.6%)	18 (9.4%)			1026 (78.4%)	282 (21.6%)
Declared current exposure to passive smoking
No		63 (36.2%)	2 (11.1%)	1.00 (Ref.)	–	530 (51.7%)	122 (43.3%)	1.00 (Ref.)	–
Yes		111 (63.8%)	16 (88.9%)	4.541 (1.011–20.393)	0.048*	496 (48.3%)	160 (56.7%)	1.401 (1.075–1.828)	0.013*
Alcohol intake
No		159 (91.4%)	16 (88.9%)	1.00 (Ref.)	–	937 (91.3%)	255 (90.4%)	1.00 (Ref.)	–
Current drinker		15 (8.6%)	2 (11.1%)	1.325 (0.278–6.321)	0.724	89 (8.7%)	27 (9.6%)	1.115 (0.709–1.752)	0.638
Declared exposure to pollution
No		76 (43.7%)	6 (33.3%)	1.00 (Ref.)	–	393 (38.3%)	96 (34.0%)	1.00 (Ref.)	–
Yes		98 (56.3%)	12 (66.7%)	1.551 (0.557–4.322)	0.401	633 (61.7%)	186 (66.0%)	1.203 (0.912–1.586)	0.191
LMDS (mean ± SD)	0.602	38.63 ± 5.36	38.83 ± 5.54	1.007 (0.920–1.102)	0.876	40.59 ± 4.98	39.57 ± 5.65	0.962 (0.937–0.987)	0.004*
BDS-22 (mean ± SD)	0.981	12.39 ± 13.82	11.89 ± 14.10	0.997 (0.962–1.034)	0.987	10.62 ± 13.61	12.91 ± 15.99	1.011 (1.002–1.020)	0.028*
Depression		3.44 ± 4.01	3.22 ± 4.07	0.986 (0.870–1.117)	0.956	2.91 ± 3.86	3.54 ± 4.65	1.037 (1.005–1.069)	0.039*
Demotivation		1.83 ± 2.78	1.67 ± 2.70	0.978 (0.815–1.174)	0.810	1.48 ± 2.60	1.90 ± 3.20	1.052 (1.005–1.100)	0.051
Psychosomatic		2.09 ± 2.72	1.94 ± 2.88	0.981 (0.816–1.178)	0.688	1.78 ± 2.65	2.11 ± 2.94	1.043 (0.995–1.092)	0.097
Mood deterioration		2.41 ± 2.35	2.06 ± 2.04	0.934 (0.752–1.161)	0.657	1.98 ± 2.25	2.33 ± 2.50	1.066 (1.009–1.126)	0.033*
Intellectual inhibition		1.36 ± 2.05	1.61 ± 2.00	1.058 (0.846–1.323)	0.265	1.27 ± 1.96	1.59 ± 2.40	1.073 (1.010–1.140)	0.040*
Anxiety		1.26 ± 1.60	1.39 ± 1.42	1.050 (0.778–1.418)	0.563	1.19 ± 1.59	1.46 ± 1.72	1.102 (1.019–1.192)	0.020*
LMAS (mean ± SD) [for 1257 patients under medical treatment]	0.870	12.59 ± 2.62	12.71 ± 2.13	1.021 (0.807–1.292)	0.904	12.83 ± 2.25	12.46 ± 2.78	0.942 (0.894–0.994)	0.048*
Occupational factor		4.41 ± 1.06	4.50 ± 0.94	1.092 (0.609–1.957)	0.848	4.52 ± 0.93	4.38 ± 1.03	0.875 (0.764–1.001)	0.065
Psychological factor		3.66 ± 0.89	3.79 ± 0.80	1.218 (0.561–2.647)	0.515	3.77 ± 0.81	3.65 ± 1.00	0.862 (0.746–0.997)	0.072
Annoyance factor		2.73 ± 0.68	2.86 ± 0.36	1.513 (0.454–5.039)	0.702	2.80 ± 0.61	2.72 ± 0.75	0.842 (0.692–1.025)	0.123
Economical factor		1.79 ± 0.62	1.57 ± 0.85	0.659 (0.319–1.362)	0.252	1.75 ± 0.67	1.71 ± 0.71	0.916 (0.753–1.115)	0.383
IPAQ n (%)	0.587
No/or low physical activity		34 (19.5%)	7 (38.9%)	1 (Ref.)	–	442 (43.1%)	153 (54.3%)	1 (Ref.)	–
Moderate physical activity		91 (52.3%)	10 (55.6%)	0.534 (0.188–1.515)	0.238	463 (45.1%)	113 (40.1%)	0.705 (0.535–0.929)	0.013*
High physical activity		49 (28.2%)	1 (5.6%)	0.099 (0.012–0.843)	0.034*	121 (11.8%)	16 (5.7%)	0.382 (0.220–0.664)	0.001*
Total sitting time/day, min (mean ± SD)		369.43 ± 180.61	447.14 ± 228.42	1.002 (1.000–1.005)	0.139	504.02 ± 199.96	530.12 ± 203.66	1.001 (1.000–1.001)	0.053

Notes: Data are presented as count (%) or mean ± standard deviation (SD). *P <0.05 was considered significant.

Abbreviations: OR, odds ratio; CI, confidence interval; LMDS, Lebanese Mediterranean diet score; BDS-22, Beirut Distress Scale; LMAS, Lebanese Medication adherence scale; IPAQ, International Physical Activity Questionnaire.

Table 4 Factors Believed to Be Associated with Cardiovascular Risk for the Women Studied

Predictors	P-value	aOR^a	95% CI
Model 1: among pre-menopausal women
Dyslipidemia	0.004*	6.938	1.835–26.224
Hypertension	0.021*	6.195	1.318–29.119
Family history of dyslipidemia	0.009*	6.143	1.560–24.191
Family history of premature CHD	0.016*	4.739	1.336–16.805
Model 2: among post-menopausal women
Dyslipidemia	<0.001*	3.018	2.102–4.332
Hypertension	0.002*	2.449	1.386–4.327
Family history of premature CHD	<0.001*	2.724	1.949–3.808
Cigarette smoking, quantification
Non-smoker (reference)	<0.001*	–	–
Up to 20 pack-years	0.818	1.061	0.639–1.763
More than 20 up to 40 pack-years	0.005*	1.881	1.206–2.935
More than 40 pack-years	<0.001*	2.317	1.574–3.410
Declared joint pain	0.023*	1.457	1.053–2.016
Monthly income per individual
Low (<180,000 LBP/month/person)/Reference	0.070	–	–
Middle (180,000–675,000 LBP/month/person)	0.029*	0.450	0.220–0.923
High (>675,000 LBP/month/person)	0.110	0.540	0.254–1.149
Place of residence
Beirut (Reference)	0.014*	–	–
Mount Lebanon (peri-urban area)	0.005*	0.589	0.406–0.854
South Lebanon/Nabatieh (rural area dominance)	0.787	0.919	0.497–1.700
North/Akkar (rural area dominance)	0.221	0.728	0.438–1.210
Bekaa/Baalback/Hermel (rural area dominance)	0.496	1.198	0.713–2.013
IPAQ
No/or low physical activity (Reference)	0.007*	–	–
Moderate physical activity	0.045*	0.725	0.529–0.992
High physical activity	0.005*	0.396	0.206–0.759
LMAS	0.088	0.950	0.895–1.008
LMDS	0.020*	0.965	0.936–0.994

Notes: ^aOdds ratios were adjusted by regression analyses for all possible confounders (particularly age). *P <0.05 was considered significant. Regression model 1 included the following variables: age, educational level, cigarette smoking-quantification, hypertension, diabetes, dyslipidemia, declared joint pain, family histories of premature CHD and dyslipidemia, declared current exposure to passive smoking, IPAQ and sedentary time. Regression model 2 included the following variables: age, place of residence, marital status, educational level, monthly income per individual, cigarette smoking-quantification, waterpipe smoking-quantification, hypertension, diabetes, dyslipidemia, declared joint pain, family histories of premature CHD and HTN, declared current exposure to passive smoking, declared exposure to pollution, LMDS, BDS-22, LMAS, IPAQ and sedentary time. The model was suitable and Hosmer-Lemeshow test was adequate (p>0.05). Absence of multi-collinearity between predictors (correlation coefficients <0.8).

Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; CHD, coronary heart disease; LBP, Lebanese pounds; LMDS, Lebanese Mediterranean Diet Score; IPAQ, International Physical Activity Questionnaire; BDS-22, Beirut Distress Scale; LMAS, Lebanese Medication Adherence Scale.