Abstract
Background. The aim of this study was to assess the prevalence and changes of cardiovascular risk factors in the middle-aged Lithuanian subjects after conducting the primary prevention program. Design and methods. Four cross-sectional investigations of cardiovascular risk factors were conducted in 2009 (n = 9625), 2010 (n = 7716), 2011 (n = 5018) and 2012 (n = 4348). The program recruited men aged 40–54 and women aged 50–64 without overt cardiovascular disease. Results. During the period 2009–2012, the mean number of risk factors significantly increased (from 3.95 to 4.03, p < 0.001), while the numbers of people having metabolic syndrome (from 34.1% to 28.7%; p < 0.001), arterial hypertension (from 60.2% to 54.5%; p < 0.001), the average body mass index (BMI) value (from 29.17 to 28.92 kg/m2; p = 0.001) and abdominal obesity (from 48.4% to 45.3%; p < 0.001) significantly decreased. The percentage of subjects with dyslipidemia, as well as the average values of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides, remained unchanged. The percentage of smoking subjects have significantly increased (from 19.3% to 22.7%; p < 0.001). Conclusions. The analysis showed that the prevalence of arterial hypertension, metabolic syndrome and obesity in Lithuania is slowly decreasing while conducting the primary prevention program; however, dyslipidemia, diabetes mellitus and smoking are still hard to manage for both genders.
Introduction and rationale
Coronary heart disease (CHD) remains the main and the most important cause of premature death all over the world, including Lithuania. According to the latest Causes of Death Register data provided by the Health Information Centre of the Institute of Hygiene (Lithuania), the structure of causes of death among the Lithuanian population remained unchanged for many years. It is important that in 2011 more than half of deaths (56.3%) were caused by cardiovascular diseases (CVD) in both men and women [within 2009–2011, the male death rate caused by circulatory system diseases (CSD) varied from 651.2 to 668.0/100 000, the female death rate from 767.2 to 758.5/100 000]. In 2012, CVD caused 56.6% of all deaths among the Lithuanian people (Citation1,Citation2). Lithuania has the highest European level of deaths from CVD (Citation3). According to the latest European guidelines on CVD prevention (2012) (Citation4), Lithuania, along with the other Eastern European countries, falls not only at the high CVD risk but is also distinguished as a very high-risk country. Despite that, data, available from the Health Information Centre of the Institute of Hygiene while conducting the Lithuanian High Cardiovascular Risk (LitHiR) primary prevention program, reveals a stable tendency of declining CHD related mortality in the middle-aged persons more in men than in women. This could be mainly explained by the ongoing countrywide clinically oriented primary LitHiR prevention program (Citation5), as well as the improvement of infrastructure for the treatment of CHD patients – the Eastern Lithuania Cardiology Project and its development to the Central and Western Lithuania regions under the financial support of the EU structural funds.
To partially overcome the existing situation, it is possible to improve the control of risk factors, which have an important bearing on cardiovascular pathology. The control of these risk factors reduces the death rate and morbidity of people with both diagnosed and undiagnosed CVD (Citation6). Thus, the preventive program promotes not only doctors but everyone to be aware of their health, eliminate or reduce risk factors, which cause cardiovascular dysfunction, and also promotes preventive check-ups.
We have tried to make an attempt to analyze the dynamics of the main risk factors in primary prevention settings in our country – to see where the roots of positive changes lie and what are the reasons still not allowing to develop the whole community cardiovascular mortality data. The aim of this study was to assess the prevalence and changes of the cardiovascular risk factors in the middle-aged Lithuanian subjects.
Methods
Four cross-sectional investigations of the selected cardiovascular risk factors were conducted in 2009 (n = 9625), 2010 (n = 7716), 2011 (n = 5018) and 2012 (n = 4348). We analyzed a total group of 26 707 subjects included in the program at the primary level in 2009–2012. The LitHiR program recruited 40–54-year-old men and 50–64-year-old women without overt CVD from all Lithuanian regions. In the program, 91.6% (385/420) of all primary care institutions, which uniformly cover the whole country, participated. In 2009–2012, in total 620 108 persons (18.09–27.44% from all target population) were examined. Participants underwent the risk profile – lifestyle (smoking, physical activity, dietary patterns) – analysis, personal and family patterns of CVD in the first degree blood relatives, anthropometry [height, weight, waist circumference and body mass index (BMI), defined as weight in kilograms divided by height (in square meters), blood pressure and pulse determination]. Blood pressure was measured in a sitting position after at least a 5-min rest in a dominant arm. The participant's dominant arm was supported at heart level and correctly sized cuffs were used. It was recommended to take the average of three measurements. Serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and calculated low-density lipoprotein-cholesterol (LDL-C) were carried out and plasma glucose was sampled for the estimation of fasting blood glucose levels. The overall cardiovascular risk, according to the risk estimation Systematic Coronary Risk Evaluation (SCORE) system, was calculated.
Arterial hypertension (AH) was determined when arterial blood pressure was ≥ 140 mmHg and/or diastolic blood pressure was ≥ 90 mmHg, or the diagnosis of hypertension was documented in a medical record. Dyslipidemia was considered if TC was > 5 mmol/l, or LDL-C > 3 mmol/l or HDL-C < 1.0 mmol/l in men and < 1.2 mmol/l in women, or TG > 1.7 mmol/l (Citation4). Metabolic syndrome (MS) was assessed according to the National Cholesterol Education Program III modified criteria. Insufficient physical activity was considered as doing aerobic exercises less than three times a week with sessions shorter than half an hour. An unbalanced diet was defined as eating food not having enough fiber, exceeding 30% of the fat percentage of calorie count, having total fat count composed of more than one third of saturated fat or consuming more than 300 mg of cholesterol per day. A family history of CHD was considered when having first- to third-generation relatives with the history of CHD or death from coronary diseases.
The calculation of the total number of risk factors was based on the following binary risk factors: hypertension, dyslipidemia, diabetes mellitus (DM), abdominal obesity, smoking, MS, inadequate physical activity, nutrition imbalance and family history of CHD.
Statistical analysis
For continuous variables, the following descriptive statistics are reported: means, standard deviations (SD) and 95% confidence interval (CI). For categorical data, frequencies are reported. In case of dichotomous categorical variables, we also provide confidence intervals for proportions of interest (e.g. DM, smoking, etc.). These intervals are obtained using the relationship between beta and binomial distributions. Continuous variables were compared with the help of the Kruskal–Wallis univariate analysis of variance (ANOVA). Categorical variables were compared with the help of the chi-square test. All reported p-values were two-tailed. The level of significance was set to 0.05.
Results
Sample characteristics
Cardiovascular risk factors were examined in 2009 in 9625 persons (3592 males, 6033 females); in 2010, 7716 (3109 males, 4607 females); in 2011, 5018 (2203 males, 2815 females) and in 2012, 4348 (1912 males, 2436 females). The average age of the participating subjects during the 4-year period declined statistically significantly (2009, 52.94 ± 6.02 years; 2010, 52.61 ± 6.15; 2011, 52.10 ± 6.18; 2012, 51.94 ± 6.22; p < 0.001).
Trends in the number of risk factors and family history
In 2009, 74.6% of the examined subjects (70.1% males, 77.2% females); in 2010, 75% (70.9% males, 77.8% females); in 2011, 73.3% (70.4% males, 75.5% females) and in 2012, 78.3% (77.9% males, 78.6% females) had three or more risk factors. The difference in the increasing numbers of subjects was statistically significant. The percentage of subjects without any risk factors had not changed. The mean number of risk factors during this period increased significantly for both genders (2009, 3.95; 2010, 3.94; 2011, 3.80; 2012, 4.03; Kruskal–Wallis criteria H(3) = 38.049, p < 0.001).
Trends in anthropometric parameters
The mean BMI value decreased significantly year- by-year (2009, 29.17 ± 5.53 kg/m2; 2010, 29.03 ± 5.52 kg/m2; 2011, 28.8 ± 5.63 kg/m2; 2012, 28.92 ± 5.51 kg/m2; p = 0.001), as well as the percentage of people with obesity (2009, 38.3%; 2010, 37.2%; 2011, 35.9%; 2012, 37.8%; p = 0.031) and with abdominal obesity (2009, 48.4%; 2010, 46.6%; 2011, 43.6%; 2012, 45.3%; p < 0.001). Furthermore, there was no statistically significant change in waist circumference over the years (2009, 94.42 ± 13.64 cm; 2010, 94.39 ± 13.62 cm; 2011, 93.95 ± 13.94 cm; 2012, 94.14 ± 14.08 cm; p = 0.179). A considerable difference in the prevalence of abdominal obesity between males and females was found – males were less obese (2009, 30.2% vs 59.3%; 2010, 29.8% vs 57.9%; 2011, 27.9% vs 55.9%; 2012, 30.9% vs 56.6%).
Trends in lifestyle habits
There was a significant upward trend in the number of smoking subjects (2009, 19.3%; 2010, 21.2%; 2011, 22.9%; 2012, 22.7%; p < 0.001) in the whole group, although the numbers were lower than they had been before the conduction of the LitHiR program. Significant increase in the prevalence of smoking among females (p = 0.013) and no change in smoking habits among males (p = 0.554) were found during this period. It was also pointed out that the number of smoking male subjects was five times higher than the number of smoking females ().
Figure 1. Smoking prevalence between males and females within 2009–2012.
In addition, there was a significant downward trend in the number of women with low physical activity until 2011, but it started rising again in 2012 (2009, 55.5%; 2010, 54.2%; 2011, 52.6%; 2012, 57.4%; p = 0.003), and a significant upward trend in the number of men (2009, 42.3%; 2010, 43.5%; 2011, 43.6%; 2012, 51.2%; p < 0.001). The total number of subjects with unbalanced diet (2009, 59.8%; 2010, 61.7%; 2011, 63.2%; 2012, 71.4%; p < 0.001) as well as the number of males (2009, 59.1%; 2010, 61.9%; 2011, 64.5%; 2012, 75.2%; p < 0.001) and the number of females (2009, 60.1%; 2010, 61.6%; 2011, 62.1%; 2012, 68.3%; p < 0.001) also had a significant increase.
Trends in blood pressure, prevalence, treatment and control of hypertension
There was also a marked decrease in the percentage of subjects with AH (2009, 60.2%; 2010, 57.9%; 2011, 53.0%; 2012, 54.5%; age-adjusted p < 0.001). The number of AH patients with the stage 3 elevation of blood pressure varied over the years (2009, 3.3%; 2010, 3.9%; 2011, 2.9%; 2012, 3.5%; p = 0.018) but was relatively low. The number of individuals on antihypertensive medications decreased significantly (2009, 72.8%; 2010, 68.3%; 2011, 66.3%; 2012, 63.4%; age-adjusted p-value < 0.001). While applying medical treatment, AH control had also had a significant downward trend (2009, 26.3%; 2010, 22.1%; 2011, 26.3%; 2012, 23.6%; p < 0.001) ().
Table I. Blood pressure (mean± SD), prevalence, treatment and control of arterial hypertension between 2009 and 2012 in Lithuania.
Trends in lipids
During the 4-year period, the percentage of subjects with dyslipidemia remained very high in both genders (). In addition, the percentage of subjects with severe dyslipidemia was also approximately equal (2009, 10.8%; 2010, 11.3%; 2011, 10.6%; 2012, 10.1%). In both cases, data varied and was not statistically significant.
Table II. Lipid parameters between 2009 and 2012 in Lithuania.
Trends in diabetes mellitus, glucose and metabolic syndrome
It was also identified that the number of people with MS had significantly decreased (2009, 34.1%; 2010, 30.5%; 2011, 29.0%; 2012, 28.7%; p < 0.001). Furthermore, while analyzing the prevalence differences of MS between males and females, it was found out that during 2009–2012 the decrease in MS prevalence amongst women was statistically significant (2009, 38.9%; 2010, 34.6%; 2011, 32.7%; 2012, 31.5%; p < 0.001), whereas among men the prevalence of MS was lower, thus decreased at a smaller rate and was not statistically significant (2009, 26.1%; 2010, 24.3%; 2011, 24.4%; 2012, 25.1%; p = 0.324). Taking into consideration the percentage of subjects with DM (2009, 9.8%; 2010 –10.5%; 2011, 9.8%; 2012, 10.2%; p = 0.322), no statistically significant difference was found. The average of fasting glucose during this period decreased significantly (2009, 5.4 ± 1.13 mmol/l; 2010, 5.45 ± 1.14 mmol/l; 2011, 5.38 ± 1.26 mmol/l; 2012, 5.31 ± 1.14 mmol/l; p < 0.001).
Discussion
Examining the prevalence of the risk factors and their dynamics during 2009–2011, the same predominant risk factors could be observed: AH, dyslipidemia, abdominal obesity, DM, MS, smoking, insufficient physical activity, unbalanced diet and family history of CVD (Citation7). Therefore, this study was designed to determine the prevalence of risk factors yearly from 2009 to 2012 and to assess their change and correction frequency during this period.
AH remains the most common risk factor for both developed and still developing countries (Citation8,Citation9). In addition, the AH level of control varies considerably between different countries (Citation10). AH is usually accompanied by lifestyle and metabolic factors (Citation4,Citation11). When comparing the results of the Lithuanian primary prevention program during 2009–2012, an annual decline can be noticed in the number of people with AH, although the prevalence of hypertension in Lithuania is still higher than in the USA and the industrialized European countries (Citation12). Due to the LitHiR primary prevention programs carried out in Lithuania (Citation6) and actively ongoing preventive educational events that encourage people to pay attention to the cardiovascular condition, more and more people are ready to give up modifiable risk factors and to attempt to change their lifestyle. While comparing the data on AH prevalence in Lithuania within 1983–2002 with the results of the LitHiR prevention program that started in 2006, it was dis-covered that AH control increased in the last years (Citation13). In Lithuania, as well as worldwide, systolic blood pressure decreases over the years (Citation14).
Dyslipidemia is another risk factor that has an important bearing on the occurrence of CVD. It has been also shown that it is possible to reduce CVD risk by 30% in a 5-year period, if a proper treatment of dyslipidemia is administered (Citation15). Comparing the prevalence of dyslipidemia in Lithuania according to our observational study, the results were similar each year and the changes were not statistically significant, whereas the results for the characteristics of individual lipidograms varied. Despite that, the continuously declining tendency does not exist and it can be concluded that the so far treatment of dyslipidemia is completely unacceptable and that dyslipidemia remains a poorly controlled risk factor. The tendency varies greatly when comparing dyslipidemia prevalence data in different regions of the world. According to the EUROASPIRE III survey data, correction and treatment of dyslipidemia in patients with CHD, was the lowest in Lithuania in comparison with the other European countries (Citation6). According to the statistics of the American Heart Association, 15% of patients had total cholesterol levels exceeding 6 mmol/l (Citation16). Yet, another study showed, that the prevalence of dyslipidemia was 29.3% and ranged from 21% among Chinese women to 36.9% among white men (Citation17). According to EURIKA survey data, the prevalence of dyslipidemia was 57.7% (Citation18), but according to the GENOA survey, which included the examination of 2356 AH patients, the prevalence of dyslipidemia was significantly higher among the white compared with the black people (female, 64.7% vs. 49.5%, male, 78.4% vs. 56.7%, for both p < 0.001) and among men than women (p ≤ 0.02 for each ethnic group) (Citation19). According to the CINDI and MONICA studies, the prevalence of dyslipidemia is 52.2% to 81% among men and 51.3% to 87% among women with the lowest use of statins (Citation13,Citation20). The new 2012 European guidelines for CVD (Citation4) point out that the reduction of dyslipidemia and its correction are the key criteria for CVD prevention. Moreover, the usage of statins in Lithuania increased from 3.873 to 12.787 defined daily doses (DDD)/1000 inhabitants/day during the period of 2005–2012; however, it is much lower than the European average (Denmark, 97.3, Finland, 87.9, Norway, 101.5, Sweden, 68.3) (Citation21). Therefore, epidemic of dyslipidemia in Lithuania still goes on because dyslipidemia on average is diagnosed in 90% of subjects () and that it is related not only to unfavorable lifestyle habits but mainly to the low use of statins at all.
The prevalence of overweight and obesity epidemic is spreading throughout the world, for which the term “Globesity” (global obesity) has already been created. Since 2008, the World Health Organization has stated that 1.5 billion of adults aged 20 years and older were overweight (BMI = 25.0–29.9 kg/m2), of which more than 200 million men and nearly 300 million women are obese (BMI > 30 kg/m2) (Citation22). Obesity also increases with the age at least up to 50 or 60 years. In Lithuania, extremely hazardous, severe and very severe obesity affects about 62 600 people (Citation23). This is one of the most important risk factors of cardiovascular and various other diseases. According to our data, from 2009 to 2012 the number of people with obesity had a significant downward trend from 38.3% to 37.8%. The USA remains the leading country according to the number of obese people. Within 2009–2010, the prevalence of obesity was 35.5% among men and 35.8% among women (the age of the subjects was at least 20 years) (Citation24). In the Central and Eastern Europe, abdominal obesity was diagnosed in 47.2% of hypertensive patients (Citation25).
MS is a collection of conditions which, when taken together, dramatically increase the risk of development of atherosclerosis, related CVD and DM (Citation12). It was found that MS increases the probability of death due to cardiovascular causes from 2.6 to 4.2 times, and the overall mortality from 1.9 to 2.1 times (Citation26). Comparing the results of our study from 2009 to 2012, the number of people with MS significantly decreased from 34.1% to 28.7%. In the USA, MS affects an estimated one-third of overweight or obese people (Citation27). The Finnish population survey (n = 3495) showed that the prevalence of MS was 48.8% in 1992 and 52.6% in 2002 (Citation28). The other CVD risk factor, which is clearly correlated with the frequency of MS, is type 2 DM. According to our study, the percentage of DM cases within 2009–2012 did not change significantly (p = 0.322) and was on a stable level of 10.1%, which did not exceed the levels of the other European countries. In the USA, DM has been diagnosed in 25.8 million people (or 8.3% of the total population) (Citation29). In 2010, the European statistics showed that there were 55.4 million people living with DM and it was assumed that this number would increase over time (Citation30).
Cigarette smoking is among the most important modifiable risk factors for adverse health outcomes and a major cause of morbidity and mortality. It was found that smoking a pack of cigarettes daily doubles the risk of myocardial infarction, and smoking even more cigarettes further increases the risk. In Lithuania, the percentage of smokers decreased greatly during the last 12 years (Citation31). That was mainly related to the public preventive measure – prohibition to smoke in public places took effect in 2006. Despite that, intimidating tendency of increasing smoking habit every year in both men (from 39.4% to 39.6%) and women (from 7.4% to 9.4%) was observed in our study. The tobacco epidemic is one of the major public health challenges in Europe as well. In the WHO European region, smoking is responsible for 1.6 million premature deaths (Citation32). In the enlarged European Union (EU25), smoking kills more than 650 000 people every year and 13 million Europeans currently suffer from tobacco-related chronic diseases (Citation33). To sum it up, additional activities in the country are needed to stop the unfavorable tendency of the smoking habit.
Insufficient physical activity is the fourth leading risk factor for mortality (Citation34). Summarizing the results of our study, we can suggest that the number of middle-aged persons whose physical activity is insufficient slowly decreases. According to the WHO, the prevalence of inadequate physical activity rose according to the level of income. High-income countries had more than double the prevalence compared with low-income countries for both men and women, with 41% of men and 48% of women being insufficiently physically active in high-income countries compared with 18% of men and 21% of women in low-income countries. Nearly every second woman in high-income countries was insufficiently physically active. This data may be explained by the increased work and the use of public transport-related physical activity for both men and women in the low and lower-middle-income countries. The increased automation of work and life in higher-income countries creates opportunities for inadequate physical activity. There are many affordable possibilities in our country – sport, fitness clubs, nice surroundings, etc.
Balanced diet is important for treatment and prevention of many diseases. In Lithuania, the number of people who have an unbalanced diet is still growing every year. This risk factor is especially emphasized in America, where fast food restaurants are extremely popular (Citation35). Therefore, more and more effort is put to promote healthy eating and to clarify that although saturated fats are part of a diet that can negatively affect cardiovascular health, there are healthy foods that can put a positive spin on your heart’s vessels. Research shows that dark chocolates, nuts and minor amounts of wines are foods that reduce LDL-C. Consuming foods that are high in omega-3 fatty acids is another great way to keep your blood vessels in shape (Citation36).
Limitation of the study
It is important to be aware of several limitations of our results. The present study examines a sample of 40–55 years old men and 50–65 years old women. A future study is needed to examine the younger and the older samples. Some risk factors, which are important in risk assessment, such as psychosocial factors, social class and others, were not taken into account. In addition, physical activity status, smoking and nutrition habits were assessed by self-reporting; therefore, the subjects may be misclassified.
Conclusions
Lithuania is still considered a country having very high cardiovascular risk, although the LitHiR preventive program has been started in 2006 with the intention of lowering the prevalence of risk factors and protecting against CVD. Although there is a permanent tendency of decrease in cardiovascular mortality in the middle-aged persons, the profile of risk factors is still unfavorable. In spite of that, some positive trends are found in the control of hypertension, MS, the average BMI value and abdominal obesity. The most unfavorable situation is related to an uncontrolled dyslipidemia. Prevalence of a smoking habit increased in recent years despite being lower than one before starting the preventive program. To sum up, the LitHiR prevention program has a positive impact on the prevalence of cardiovascular risk factors.
Acknowledgements
This research is funded by the European Social Fund under the Global Grant measure.
Conflict of interest: None of the authors has any financial interest for this paper.
References
- Health Information Centre of the Institute of Hygiene. Causes of death 2011; 2012.
- Laucevicius A, Rinkuniene E, Skorniakov V, Petrulioniene Z, Kasiulevicius V, Jatuzis D. High-risk profile in a region with extremely elevated cardiovascular mortality. Hellenic J Cardiol. 2013;54:441–447.
- Statistical Office of the European Union. Death due to ischaemic heart diseases, by sex; 2013. Retrieved from http://epp.eurostat.ec.europa.eu/tgm/table.do?tab=table&init=1&plugin=1&language=en&pcode=tps00119.
- Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2012;33:1635–1701.
- Laucevicius A, Kasiulevicius V, Jatuzis D, Petrulioniene Z, Ryliskyte L, Rinkuniene E. Lithuanian High Cardiovascular Risk (LitHiR) primary prevention programme – Rationale and design. Semin Cardiovasc Med. 2012;18:3.
- Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Reiner Z. EUROASPIRE III. Management of cardiovascular risk factors in asymptomatic high-risk patients in general practice: Cross-sectional survey in 12 European countries. Eur J Cardiovasc Prev Rehabil. 2010;17:530–540.
- Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case–control study. Lancet. 2004;364:937–952.
- Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: Analysis of worldwide data. Lancet. 2005;365:217–223.
- Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: A systematic review. J Hypertens. 2004;22:9–11.
- Banegas JR, López-García E, Dallongeville J, Guallar E, Halcox JP, Borghi Cl.Achievement of treatment goals for primary prevention of cardiovascular disease in clinical practice across Europe: The EURIKA study. Eur Heart J. 2011;32:2143–2152.
- Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–1913.
- Laucevicius A, Rinkuniene E, Petrulioniene Z, Puronaite R, Kasiulevicius V, Jatuzis D. Prevalence of high-risk profile in middle-aged subjects with arterial hypertension: A nationwide survey. Blood Press. 2014;Early Online:1–7.
- Domarkienė S, Tamošiūnas A, Rėklaitienė R, Šidlauskienė D, Jurėnienė K, Markevičienė L. Trends in main cardiovascular risk factors among middle-aged Kaunas population between 1983 and 2002. Medicina. 2003;39:1193–1199.
- Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ. National, regional, and global trends in systolic blood pressure since1980: Systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants.Lancet.2011;377:568–577.
- Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. J Am Coll Cardiol. 2004;44:720–732.
- Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB. Heart Disease and Stroke Statistics – 2012 Update: A Report from the American Heart Association. Circulation. 2012;125:e2–e220.
- Goff Jr DC, Bertoni AG, Kramer H, Bonds D, Blumenthal RS, Tsai MY. Dyslipidemia prevalence, treatment, and control in the Multi-Ethnic Study of Atherosclerosis (MESA): Gender, ethnicity, and coronary artery calcium. Circulation. 2006;113:647–656.
- Guallar E, Banegas JR, Blasco-Colmenares E, Jimenez FJ, DallongevilleJ, Halcox JP. Excess risk attributable to traditional cardiovascular risk factors in clinical practice settings across Europe – The EURIKA Study. BMC Public Health. 2011;11:704–709.
- O’Meara JG, Kardia SLR, Armon JJ, Brown CA, Boerwinkle E, Turner ST. Ethnic and Sex Differences in the Prevalence, Treatment, and Control of Dyslipidemia Among Hypertensive Adults in the GENOA Study. Arch Intern Med. 2004;164:1313–1318.
- Grabauskas V, Klumbienė J, Petkevičienė J, Petrauskienė A, Tamošiūnas A, Kriaučiūnienė V. Risk factors for noncommunicable diseases in Lithuanian rural population: CINDI survey 2007. Medicina. 2008;44:633–639.
- NOMESCO. Health Statistics for the Nordic Countries 2011. Retrieved from: http://nomesco-eng.nom-nos.dk/filer/publikationer/Helsstat%202011.pdf.
- World Health Organization. Obesity and overweight 2013. Retrieved from http://www.who.int/mediacentre/factsheets/fs311/en/.
- Brimas G, Lipnickas V, Strupas K. Nutukimo gydymas. 2007, 13(2).
- Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA. 2012;307: 491–497.
- Grassi G, Cifkova R, Laurent S, Narkiewicz K, Redon J, Farsang C. Blood pressure control and cardiovascular risk profile in hypertensive patients from central and eastern European countries: Results of the BP-CARE study. Eur Heart J. 2011;32:218–225.
- Lakka HM, Laaksonen DE, Lakka TA. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA. 2002;288:2709–2716.
- Grundy SM, Hansen B, Smith SC, Cleeman JI, Kahn R. A. Clinical management of metabolic syndrome: Report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association conference on scientific issues related to management. Circulation. 2004;109:551–556.
- Hu G, Lindstroem J, Jousilahti P, Peltonen M, Sjoeberg L. The Increasing Prevalence of Metabolic Syndrome among Finnish Men and Women over a Decade. J Clin Endocrinol Metab. 2008;93:832–836.
- Diabetes Statistics – American Diabetes Association. Retrieved March 7, 2013, from http://www.diabetes.org/diabetes-basics/diabetes-statistics/?loc=DropDownDB-stats.
- Europe | International Diabetes Federation. Retrieved March 7, 2013, from http://www.idf.org/diabetesatlas/europe.
- Statistics Lithuania. Share of population daily smoking by sex. Retrieved from http://db1.stat.gov.lt.
- WHO Regional Office for Europe. The European Tobacco Control Report 2007. Copenhagen: World Health Organization; 2007.
- The ASPECT Consortium. Tobacco or health in the European Union – Past, present and future. Luxembourg: Office for Official Publications of the European Communities; 2004.
- World Health Organization. Prevalence of insufficient physical activity. Retrieved from http://www.who.int/gho/ncd/risk_factors/physical_activity_text/en/index.html.
- CBS News. Americans Are Obsessed with Fast Food: The Dark Side of the All-American Meal. Retrieved from http://www.cbsnews.com/news/americans-are-obsessed-with-fast-food-the-dark-side-of-the-all-american-meal/.
- eHow. How Does Diet Affect Cardiovascular Strength and Health?Retrieved July 21, 2013, from http://www.ehow.com/how-does_4565845_diet-affect-cardiovascular-strength-health.html.