Mohammed Altayyeb, Charles Hamilton, Amanda Srsic

Relationships between cardiovascular risk factors and lung function in Polish men
and women, aged 45-69, in Krakow City

1. Aim: The aim of this project is to investigate the relationship between cardiovascular risk
factors (Body-Mass Index (BMI), smoking status, hypertension, diabetes, hypercholesterolemia) and
lung function measured by Forced Expiratory Volume in first second (FEV 1) and Forced Vital Capacity
(FVC) in women, aged 45-69 in Krakow, Poland, enrolled in the Health, Alcohol, and Psychosocial
factors in Eastern Europe (HAPIEE) study.

The HAPIEE study is a cohort study that assesses the effects of dietary factors, alcohol consumption
and psychosocial factors on the health of men and women in four Central and Eastern European
(CEE) countries (the Czech Republic, Lithuania, Poland and Russia).(1)

The rationale for the HAPIEE study and the selected countries is largely due to their shared rapid
social, economic and epidemiological transitions.(1,2) CEE countries vital statistics reveal some of the
highest mortality rates in the world largely due to non-communicable diseases.(2,3)

The World Health Organization (WHO) cites the global burden of non-communicable diseases (NCDs)
to be unacceptably high, accounting for 71% (41M/57M) of the world’s deaths, with 15 million of
these deaths being premature.(4)

Poland’s NCDs mortality rate far outpaces global numbers, with NCDs accounting for 90% of all
deaths in the country and 19% of premature deaths.(5)

Figure 1: Proportional Mortality Rates in Poland – 2018 (5)

Among all four of the countries, cardiovascular diseases was the leading cause of death, with Poland
facing a serious challenge from cardiovascular disease, which accounts for 46% of deaths in the
country.(2,5,6)

NCD risk factors such as obesity, high body mass index, smoking status, raised blood pressure, raised
blood glucose levels and raise blood cholesterol levels have been closely studied in literature, with
global evidence showing a strong relationship between these factors and an increased risk of
cardiovascular disease incidence and prevalence.(2,4,5,7,8) Additionally, Forced Expiratory Volume in
first second (FEV1) and Forced Vital Capacity (FVC), has been explored in literature as strong
predictors for an increased risk of raised blood pressure, hypertension and cardiovascular disease.
(9,10)

Therefore, with cardiovascular diseases playing such a significant role on disease burden in Poland,
our paper aims to explore the linkages between these various risk factors and cardiovascular disease
among Polish women aged 45-69 living in Krakow.

2. Methods: Although the HAPIEE study analyzes data from men and women in Russia, Poland,
the Czech Republic, and Lithuania, this analysis will solely focus on data collected from a random,
representative sample of women, aged 45-49, living in Krakow. Participants were recruited from four
Krakow regions, Nowa Huta, Podgorze, Srodmiescie, and Krowodrza, and were assessed twice, once
in 2002-2005 and again in 2006-2008. The participants were stratified by gender and 5-year age
groups. Through a questionnaire and physical examination, data was collected on BMI, smoking
status, hypertension, diabetes, hypercholesterolemia, FEV1, and FVC.

a) Measurements

BMI was calculated as weight in kilograms divided by the square of height in meters and was coded
as a normal (1), overweight (2), or obese (3).

Smoking status was coded as a current (1), former (2), and never smoker (3).

Hypertension was defined as systolic blood pressure of ≥140 mmHg, or diastolic blood pressure of
≥90 mmHg, or when hypertension is diagnosed by the doctor. Hypertension was then coded into
categories of “yes” (1) or “no” (2).

Diabetes was defined as blood glucose levels ≥7.1 mmol/L or when diabetes was diagnosed by
doctor. Diabetes was then coded into categories of “yes” (1) or “no” (2).

Hypercholesterolemia was defined as total cholesterol levels ≥5 mmol/L, when LDL cholesterol ≥3
mmol/L, or when hypercholesterolemia was diagnosed by the doctor. Hypercholesterolemia was
then coded into categories of “yes” (1) and “no” (2).

In the current study, we used two measures describing lung function: forced vital capacity (FVC) and
forced expiratory volume in 1 second (FEV1).

Reference values for these parameters were calculated based on age and height according to
standardized lung function testing from the official statement of the European Respiratory Society.
The percentage of predictive value of FVC was calculated by dividing Actual FVC by Parameter FVC.

b) Statistical analysis

Descriptive statistics were calculated with means and standard deviations reported for quantitative
variables, and data of categorical variables were reported using frequency tables.

T-tests or One-Way ANOVA (for three or more categories) were conducted to compare the means
between categories for both %FEV1 and %FVC. Normality was confirmed by plotted histograms and
results of Shapiro-Wilk and Kolmogorov Smirnov tests (see Figures 2 and 3).

To confirm the homogeneity of variances of %FVC and %FEV 1, the Levene (ANOVA) or Fisher (T-Test)
tests were conducted (see Figures 6-15 in annex).
When significant results were obtained from ANOVA tests, post-hoc analysis (Tukey and Scheffe) was
conducted to identify in which category did the differences occur.

3. Results

a) Univariate Analysis

A total of 660 patients were included in the final analysis. Descriptive statistics of the study group are
presented in Table 1.

The mean age was 56.72 years, with a standard deviation of 7.11 years.

According to BMI data, in our sample 181 (27.5%) people are in the “normal” category, 248 (37.7%)
people are in the “overweight” category, and 228 (34.7%) people are “obesity” category.

There are 156 (23.7%) people who are current smokers, 125 (19%) people who are former smokers,
and 377 (57.3%) people who have never smoked.

There are 410 (62.3%) persons categorized as hypertensive, and 248 (37.7%) persons that do not
have hypertension.

There are 77 (11.7%) people who have diabetes, and 585 (88.3%) people who do not have diabetes.

There are 590 (89.5%) people that have been categorized as having hypercholesterolemia, and 69
(10.5%) people that have been categorized as not having hypercholesterolemia.

Mean FVC in our sample was 273.38 cl with a standard deviation of 54.31 cl, while FEV 1 was 227.00
with a standard deviation of 49.21 cl.

Adjusting for age and height differences within our sample, %FVC was 102.01 cl with a standard
deviation of 16.64 cl, while %FEV1 was 100.48 cl with a standard deviation of 17.89 cl.

Table 1. Descriptive statistics of the studied group.

N= 660
Age (years) [mean,sd] 56.72 7.11
Level of education [n, %]
Incomplete or no formal education 0 0.00
Primary 85 12.9
Vocational (apprenticeship) 95 14.4
Secondary 306 46.4
University (Degree) 173 26.3
BMI (n, %)
Normal 181 27.5
Overweight 248 37.7
Obesity 228 34.7
Smoking status [n, %]
Current 156 23.7
Former 125 19.0
 Never 377 57.3

Hypertension [n, %]
Yes 410 62.3
No 248 37.7
Diabetes [n, %]
Yes 77 11.7
No 583 88.3
Hypercholesterolemia [n, %]
Yes 590 89.5
No 69 10.5
FVC (cl) [mean, sd] 273.38 54.31
FEV1 (cl) [mean, sd] 227.00 49.21
%FEV1 [mean, sd] 100.48 17.89
%FVC [mean, sd] 102.01 16.64

Figure 2: Independent T-test, Kolmogorov-Smirnov, and Shapiro-Wilk to test for normality of %FEV1

The above figure confirms that the distribution of %FEV1 is normal.

Figure 3: Independent T-test, Kolmogorov-Smirnov, and Shapiro-Wilk to test for normality of %FVC
The above figure confirms that the distribution of %FVC is normal.

Additionally, a histogram and Levene test were used to test the homogeneity of variances between
%FEV1 and each of the CVD risk factors, as well as %FVC and each of the CVD risk factors (see figures
6-15 in the Technical Report in the attached annex). The figures confirm that the variances of both
%FEV1 and %FVC among each CVD risk factor were homogenous.

b) Multivariate Analysis

Association between BMI category and predictive value of FEV1 and FVC.

Table 2. Comparisons of means of %FEV1 and %FVC between participants in normal, overweight, and
obesity categories.

%FEV1 %FVC
n mean sd p n mean sd p
BMI Category
normal 181 101.14 18.56 181 103.13 17.03
overweight 248 101.52 17.66 0.3 248 103.45 16.50 0.03*
obesity 228 99.04 17.57 228 99.76 16.29
The ANOVA test showed significant differences in the mean values of %FVC and %FEV1 in normal,
overweight, and obesity categories. Tukey and Scheffe post-hoc analysis show a significant difference
in %FVC specifically between groups of individuals that fall into the categories of overweight and
obesity.

Figure 4: Box Plot to compare means of %FVC in each BMI category

Association between Hypertension category and predictive value of FEV 1 and FVC.

Table 3. Comparisons of means of %FEV1 and %FVC between participants with and without
hypertension.

%FEV1 %FVC
n mean sd p n mean sd p
Hypertension
0 (No) 248 101.83 17.88 248 103.38 16.55
0.1 0.1
1 (Yes) 410 99.66 17.88 410 101.22 16.66

This table illustrates that the %FEV1 and %FVC is not statistically significant among individuals with
and without hypertension.

Association between Hypercholesterolemia category and predictive value of FEV 1 and FVC.

Table 4. Comparisons of means of %FEV1 and %FVC between participants with and without
hypercholesterolemia.

%FEV1 %FVC
n mean sd p n mean sd p
Hypercholesterolemia
0 (No) 69 97.46 17.92 69 99.19 16.15
0.1 0.1
1 (Yes) 590 100.82 17.88 590 102.33 16.69
This table demonstrates that the %FEV1 and %FVC is not statistically significant among individuals
with and without hypercholesterolemia.

Association between Diabetes and predictive value of FEV1 and FVC.

Table 5. Comparisons of means of %FEV1 and %FVC between participants with and without diabetes.

%FEV1 %FVC
n mean sd p n mean sd p
Diabetes
0 (No) 583 100.88 17.6 583 102.5 16.32
0.1 0.04*
1 (Yes) 77 97.49 19.82 77 98.35 18.55

The T-test shows a significant difference in %FVC between individuals that have diabetes and those
that do not have diabetes. The higher mean values of %FVC was observed in participants without
diabetes.

Figure 4: Box Plot to compare means of %FVC in participants with and without diabetes

Association between Smoking Status and predictive value of FEV 1 and FVC.

Table 6. Comparisons of means of %FEV1 and %FVC between participants with and without smoking
status.

%FEV1 %FVC
n mean sd p n mean sd p
Smoking Status
1 (Current) 156 95.59 18.45 156 99.4 15.58
2 (Former) 125 99.33 16.92 <0.001* 125 101.51 17.29 0.05*
3 (Never) 377 102.83 17.57 377 103.2 16.76
Tukey and Scheffe post-hoc analysis show a significant difference between current and never smokers
in their %FEV1 and %FVC measurements.

Figure 5: Box Plots to compare means of %FEV1 and %FVC in each category of Smoking Status

According to this study, BMI and diabetes status do not have a significant effect on %FEV 1, while
neither hypertension nor hypercholesterolemia status have a significant effect on %FEV 1 or %FVC
measurements.

However, BMI and diabetes status have a significant effect on %FVC, while smoking status has a
significant effect on both %FEV1 and %FVC. Based on these results, BMI, diabetes and smoking status
can be seen as predictors for %FVC & %FEV1 measurements.

4. Conclusion
The effects of BMI, diabetes, and smoking status on lung function offer important new insights into
social, behavioural, and biological factors that affect mortality and cardiovascular risk in the region.
Given the link between lung function and high blood pressure and cardiovascular disease incidence,
interventions to combat NCDs can be fine-tuned to take this evidence into consideration, better
targeting these risk factors and ultimately reducing the burden of NCDs in Poland.
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Annex: Technical Report

The histogram and results of the Levene test are displayed below for each CVD risk factor and both
measures of lung function.

Figure 6: Histograms and Levene test output to compare the homogeneity of variances of %FEV1 and
BMI categories

The above figures confirm that the variance of %FEV1 among BMI categories is homogeneous.
Figure 7: Histograms and Levene test output to compare homogeneity of variances between
variables %FVC and BMI category

The above figures confirm that the variance of %FVC among BMI categories is homogeneous.
Figure 8: Histograms and Levene test output to compare homogeneity of variances between %FEV1
and hypertension categories

The above figures confirm that the variance of %FEV1 among hypertension categories is
homogeneous.
Figure 9: Histograms and Levene test output to compare homogeneity of variances between
variables %FVC and hypertension category

The above figures confirm that the variance of %FVC among hypertension categories is
homogeneous.
Figure 10: Histograms and Levene test output to compare homogeneity of variances between
variables %FEV1 and hypercholesterolemia category

The above figures confirm that the variance of %FEV1 among hypercholesterolemia categories is
homogeneous.
Figure 11: Histograms and Levene test output to compare homogeneity of variances between
variables %FVC and hypercholesterolemia category

The above figures confirm that the variance of %FVC among hypercholesterolemia categories is
homogeneous.
Figure 12: Histograms and Levene test output to compare homogeneity of variances between
variables %FEV1 and diabetes category

The above figures confirm that the variance of %FEV1 among diabetes categories is homogeneous.
Figure 13: Histograms and Levene test output to compare homogeneity of variances between
variables %FVC and diabetes category

The above figures confirm that the variance of %FVC among diabetes categories is homogeneous.
Figure 14: Histograms and Levene test output to compare homogeneity of variances between %FEV1
and smoking categories

The above figures confirm that the variance of %FEV1 among smoking categories is homogeneous.
Figure 15: Histograms and Levene test output to compare homogeneity of variances between
variables %FVC and smoking category

The above figures confirm that the variance of %FVC among smoking categories is homogeneous.