Influence of physical activity,the Mediterranean diet and sociodemographic variables on the values of different cardiovascular risk scales

Abstract

INTRODUCTION:

Cardiovascular disease (CVD) continues to be one of the main causes of morbidity and mortality in the world. There are several risk factors for CVD, many of which are preventable, including sedentary lifestyles and poor diet.

OBJECTIVE:

To assess the influence of physical activity, adherence to the Mediterranean diet and sociodemographic variables such as age, sex and social class on the values of different cardiovascular risk scales.

METHODS:

A descriptive, cross-sectional study in 1584 Spanish workers in which the influence of different sociodemographic variables (age, sex, social class) and healthy habits (tobacco consumption, physical activity assessed with the IPAQ questionnaire, and adherence to the Mediterranean diet) on the values of different cardiovascular risk (CVR) scales (REGICOR, SCORE, DORICA, ERICE, heart age, and vascular age) was assessed.

RESULTS:

All the CVR scales showed better mean values as the level of physical activity increased, something similar occurring with the prevalence of altered values, in both sexes. High adherence to the Mediterranean diet also improved the mean values and prevalence of altered values in men and women.

CONCLUSION:

The Mediterranean diet and physical exercise decrease the probability of suffering a cardiovascular event and improve all the CVR scales analyzed in this study.

Keywords

Cardiovascular disease physical activity Mediterranean diet

1 Introduction

Cardiovascular disease (CVD) is currently one of the most important causes of morbidity, mortality and disability in Spain [1]. Strategies to reduce the risk of suffering this type of pathology focus on high-risk individuals who can be identified by means of cardiovascular risk (CVR) calculators, which are considered essential for primary prevention because they are easy and quick to use and very low cost, making them ideal for population screening, which is why most clinical guidelines [2 –5] incorporate them as fundamental elements for prevention and clinical decision making.

There are numerous scales for assessing CVR that use similar parameters, such as the Framingham equation [6] used essentially for the US population, the SCORE [7] scale for the European population, and the QRISK3 [8] model used in the UK. In Spain, the most widely used scale is REGICOR [9] which is an adaptation of the Framingham scale to the Spanish population.

The ICARIA study, conducted in workers, found a high prevalence of different CVR factors, metabolic syndrome, and high values in CVR scales. This same study [10] found a greater duration and cost of sick leave due to illnesses, not only cardiovascular, in people with moderate and high values in the CVR scales.

The aforementioned tables evaluate risk over a 10-year period, and can be used from the age of 35–40 years. However, a large proportion of young adults who are at low risk would possibly be at higher risk if longer periods of time or remaining years of life were assessed, which is why the latest recommendations of the cardiovascular prevention guidelines recommend the calculation of lifetime risk or vascular age [2].

A cardiovascular risk factor (CVRF) is understood to be a biological parameter or unhealthy habit that increases the probability of suffering a cardiovascular event; the presence of a factor does not imply that CVD will always occur, nor does the absence of a CVRF prevent CVD from occurring.

CVRFs can be divided into non-modifiable –including age, sex, and genetic factors –and modifiable –such as arterial hypertension, dyslipidemia, diabetes mellitus, obesity, tobacco use, sedentary lifestyle, and poor diet. These modifiable factors are the most important because they are preventable [11]. Physical activity and a healthy diet have been shown to be effective in preventing cardiovascular risk. Sedentary behavior and physical inactivity are among the leading modifiable risk factors worldwide for cardiovascular disease and all-cause mortality. Psychosocial factors are currently gaining prominence and include the most disadvantaged social classes, depression, and family- and work-related stress [12].

The aim of this study was to assess the effect of some CVRFs, especially modifiable ones such as physical activity –determined with the IPAQ questionnaire –and a heart-healthy diet –assessed by adherence to the Mediterranean diet –on the values of different CVR scales such as REGICOR, SCORE, DORICA, ERICE, heart age, Framingham vascular age, and SCORE vascular age.

2 Material and methods

A descriptive, cross-sectional study was conducted in 1584 Spanish workers from different productive sectors during the period between January 2017 and December 2017. Of the total, 127 were excluded (69 for not accepting to participate and 58 for being under 20 years old) finally leaving 1457 workers who were included in the study, 718 of whom were women (mean age 43.30 years) and 739 men (mean age 46.02 years). Workers were selected from among those who attended periodic occupational medical check-ups.

2.1 Inclusion criteria

Aged between 18 and 67 years.

Being an active worker.

Belonging to one of the companies collaborating in the study.

Agreeing to participate in the study.

2.2 Determinations

Anthropometric, clinical, and analytical measurements were taken by the health personnel of the occupational health units participating in the study, after homogenizing the measurement techniques.

Weight (in kilograms) and height (in cm) were determined with a SECA 700 mechanical column scale with a capacity of 200 kg and a SECA 220 telescopic measuring rod with millimetric division and a 60–200 cm interval.

Abdominal and hip waist were measured with a SECA model 200 tape measure, with an interval of 1–200 cm and millimetric division. The person was in a standing position with feet together and trunk erect, abdomen relaxed, and upper extremities hanging on both sides of the body. The tape measure was placed parallel to the floor at the level of the last floating rib. For hip circumference, the same position was adopted as for the waist and the tape measure was placed horizontally at hip level.

Blood pressure was determined in the supine position with a calibrated OMRON M3 automatic sphygmomanometer after 10 minutes of rest. Three measurements were obtained at one-minute intervals and the mean of the three was obtained. Blood analysis was performed after 12 hours of fasting. Samples were sent to reference laboratories. Glycemia, total cholesterol, and triglyceride measures used automated enzymatic methods, with values expressed in mg/dL. HDL was determined by precipitation with dextran sulfate Cl2Mg, and values were also expressed in mg/dL. LDL was calculated using the Friedewald formula (provided that triglycerides were less than 400 mg/dL). Values were expressed in mg/dL.

Friedewald formula: LDL = total cholesterol –HDL–triglycerides/5

A smoker was considered to be a person who regularly consumed at least 1 cigarette/day (or the equivalent in other types of consumption) in the previous month, or who had stopped smoking less than a year before.

Social class was obtained from the 2011 National Classification of Occupations (NCO-11) based on the proposal made by the social determinants group of the Spanish Society of Epidemiology [13]. We opted for classification in 3 categories: Class I. Directors/managers, university professionals, athletes, and artists. Class II. Intermediate occupations and self-employed workers without employees. Class III. Unskilled workers.

To assess diet, a questionnaire of adherence to the Mediterranean diet [14] was used with 14 questions, each rated with 0 or 1 point. Values below 9 were considered low adherence and above 9, high adherence.

The IPAQ (International Physical Activity Questionnaire) was used to assess physical activity [15]. It is a self-administered questionnaire consisting of 7 questions that assesses the physical activity performed in daily life in the last 7 days.

REGICOR (Registro Gironí del Cor) is an adaptation of the Framingham scale to the characteristics of the Spanish population by means of a well-tested calibration process. The scale has been validated in the Spanish population [16]. It estimates the risk of suffering a fatal or non-fatal cardiovascular event over a 10-year period. The tables are applied to persons between 35 and 74 years of age. To calculate risk, age, sex, smoking, diabetes, systolic and diastolic blood pressure, total cholesterol, and HDL-c are taken into account. To classify the level of risk with the REGICOR tables, the recommended cut-off points [17] were used, considering moderate from 5%, high from 10%, and very high for values of 15%or more.

The SCORE (Systematic Coronary Risk Evaluation) scale is based on data obtained in different European populations, wherefore there are different tables depending on the level of risk in each country [18]. In our study, we used the version for low-risk countries, recommended for Spain [19], which estimates the risk of suffering a fatal cerebrovascular event over a 10-year period. The tables are applied to people between 40 and 65 years of age. To calculate risk, age, sex, smoking, systolic blood pressure, total cholesterol, and HDL-c are taken into account. To classify the level of risk with the SCORE tables, the recommended cut-off points [20] were used: moderate when values are between 4–5%and high from 5%onwards.

DORICA (Dyslipidemia Obesity and Cardiovascular Risk in Spain). This scale is based on the DORICA study [21] which was conducted in a very large Spanish population base. It estimates the risk of suffering a fatal or non-fatal cerebrovascular event over a 10-year period. The tables are applied to people between 25 and 64 years of age. To calculate risk, age, sex, smoking, diabetes, systolic and diastolic blood pressure, total cholesterol, and HDL-c are taken into account. To classify the level of risk with the DORICA tables, the cut-off points recommended by the group responsible for the study were used, where risk is moderate when it presents values between 10%and 19%, high from 20%, and very high if it exceeds 39%.

ERICE (Spanish Cardiovascular Risk Equation) is based on seven population-based cohort studies conducted in different geographical areas of Spain [22]. It estimates the risk of suffering a fatal or non-fatal cerebrovascular event over a 10-year period. The tables apply to persons between 30 and 80 years of age. To calculate risk, age, sex, smoking, diabetes, systolic blood pressure, antihypertensive treatment, and total cholesterol are taken into account. To classify the level of risk with the ERICE tables, the cut-off points recommended by the group responsible for the study were used: risk is considered moderate if it exceeds 5%, moderate-high if it is between 15%and 19%, high if it is between 20%and 39%, and very high if it exceeds 39%.

Heart age is a tool based on the classic Framingham cardiovascular risk scale that enables calculation of a patient’s probability of developing cardiovascular disease in the next 10 years [23, 24]. To calculate heart age, the following are required: age, sex, height (in centimeters), weight (in kilograms), waist circumference (in centimeters), family history (parents) of cardiovascular disease and age when they first suffered it, presence or absence of diabetes, tobacco use (if not currently smoking, respondents are asked whether smoking has been stopped in the previous year), total cholesterol and HDL cholesterol values, systolic blood pressure values, and whether the patient is currently under antihypertensive treatment. The “Heart age calculator” tool is used for the calculation, which, in its Spanish version, is available on the web page: http://www.heartage.me. The scale is applicable between the ages of 18 and 80 years. The range of years gained or lost is 20, with a minimum age of 18 years and a maximum of 80 years. An interesting concept that can also be applied to vascular ages, which we will see below, is avoidable lost life years (ALLY) [25] which can be defined as the difference between chronological age (CA) and vascular age (VA). $ALLY = Vascular age - Chronological age$

As the meaning of ALLY is different according to the value of the CA, the ratio of ALLY to CA is defined as the ratio of avoidable lost life years (RALLY). $RALLY = ALLY / Chronological age$

In order to calculate vascular age with the Framingham model [26], we used age, sex, HDL-c, total cholesterol, systolic blood pressure values, antihypertensive treatment, smoking, and diabetes. The scale can be calculated from the age of 30 years.

Vascular age with the SCORE model [27] is calculated using age, sex, systolic blood pressure, smoking, and total cholesterol. As with the SCORE scale from which it derives, it can be calculated in people between 40 and 65 years of age.

2.3 Statistical analysis

A descriptive analysis of the categorical variables was performed, by calculating the frequency and distribution of responses for each variable. The Kolmogorov-Smirmov test is performed to demonstrate the normal distribution of the sample. For quantitative variables, the mean and standard deviation were calculated, whereas for qualitative variables, the test (with correction for Fisher’s exact statistic when conditions required it) and Student’s t test for independent samples were carried out. For the multivariate analysis, binary logistic regression was used with the Wald method, with calculation of the Odds ratio, and the Hosmer-Lemeshow goodness-of-fit test was performed. Statistical analysis was conducted with the SPSS 27.0 program, the accepted level of statistical significance being 0.05.

2.4 Ethical considerations and aspects

The study was approved by the Clinical Research Ethics Committee of the Balearic Islands Health Area, no. IB 4383/20. All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 2013 Declaration of Helsinki. All patients signed written informed consent documents before participating in the study.

3 Results

Table 1 shows the anthropometric, clinical, analytical, sociodemographic and healthy habits characteristics of our population, showing that the values were more unfavorable, except for total cholesterol and tobacco consumption, among men.

Table 1
Characteristics of the population

Women (n = 718) mean (SD) Men (n = 739) mean (SD) Total (n = 1457) mean (SD) p-value

Age (years) 43.30 (8.44) 46.02 (8.50) 44.68 (8.57) < 0.0001

Weight (kg) 66.29 (12.29) 82.24 (13.81) 74.38 (15.32) < 0.0001

Height (m) 1.62 (0.06) 1.73 (0.07) 1.68 (0.09) < 0.0001

Body mass index (kg/m²) 25.36 (4.61) 27.40 (4.13) 26.39 (4.49) < 0.0001

Waist circumference (cm) 89.44 (16.36) 97.00 (10.65) 93.27 (14.27) < 0.0001

Hip circumference (cm) 105.78 (13.22) 108.77 (10.27) 107.29 (11.91) < 0.0001

Systolic Blood Pressure (mm Hg) 121.31 (17.05) 133.76 (18.11) 127.62 (18.66) < 0.0001

Diastolic Blood Pressure (mm Hg) 75.03 (10.58) 80.63 (11.43) 77.87 (11.36) < 0.0001

Total cholesterol (mg/dl) 186.02 (31.14) 183.37 (31.72) 184.67 (31.46) 0.108

HDL-c (mg/dl) 60.18 (13.55) 49.83 (12.16) 54.93 (13.86) < 0.0001

LDL-c (mg/dl) 107.88 (28.16) 108.94 (29.15) 108.42 (28.66) 0.483

Triglycerides (mg/dl) 86.57 (43.59) 119.55 (87.42) 103.30 (71.28) < 0.0001

Glycemia (mg/dl) 92.16 (16.31) 98.68 (19.54) 95.47 (18.30) < 0.0001

% % % p-value

< 35 years 16.71 10.42 13.52 < 0.0001

35–49 years 57.80 51.01 54.36

≥50 years 25.49 38.57 32.12

Social class I 18.94 8.80 13.80 < 0.0001

Social class II 63.65 82.67 73.30

Social class III 17.41 8.53 12.90

No tobacco 71.87 72.94 72.41 < 0.0001

Yes tobacco 28.13 27.06 27.59

MET low 23.68 19.08 21.35 < 0.0001

MET moderate 48.05 36.40 42.14

MET high 28.27 44.52 36.51

Predimed low 36.49 48.17 42.42 < 0.0001

Predimed high 63.51 51.83 57.58

	Women (n = 718) mean (SD)	Men (n = 739) mean (SD)	Total (n = 1457) mean (SD)	p-value
Age (years)	43.30 (8.44)	46.02 (8.50)	44.68 (8.57)	< 0.0001
Weight (kg)	66.29 (12.29)	82.24 (13.81)	74.38 (15.32)	< 0.0001
Height (m)	1.62 (0.06)	1.73 (0.07)	1.68 (0.09)	< 0.0001
Body mass index (kg/m²)	25.36 (4.61)	27.40 (4.13)	26.39 (4.49)	< 0.0001
Waist circumference (cm)	89.44 (16.36)	97.00 (10.65)	93.27 (14.27)	< 0.0001
Hip circumference (cm)	105.78 (13.22)	108.77 (10.27)	107.29 (11.91)	< 0.0001
Systolic Blood Pressure (mm Hg)	121.31 (17.05)	133.76 (18.11)	127.62 (18.66)	< 0.0001
Diastolic Blood Pressure (mm Hg)	75.03 (10.58)	80.63 (11.43)	77.87 (11.36)	< 0.0001
Total cholesterol (mg/dl)	186.02 (31.14)	183.37 (31.72)	184.67 (31.46)	0.108
HDL-c (mg/dl)	60.18 (13.55)	49.83 (12.16)	54.93 (13.86)	< 0.0001
LDL-c (mg/dl)	107.88 (28.16)	108.94 (29.15)	108.42 (28.66)	0.483
Triglycerides (mg/dl)	86.57 (43.59)	119.55 (87.42)	103.30 (71.28)	< 0.0001
Glycemia (mg/dl)	92.16 (16.31)	98.68 (19.54)	95.47 (18.30)	< 0.0001
	%	%	%	p-value
< 35 years	16.71	10.42	13.52	< 0.0001
35–49 years	57.80	51.01	54.36
≥50 years	25.49	38.57	32.12
Social class I	18.94	8.80	13.80	< 0.0001
Social class II	63.65	82.67	73.30
Social class III	17.41	8.53	12.90
No tobacco	71.87	72.94	72.41	< 0.0001
Yes tobacco	28.13	27.06	27.59
MET low	23.68	19.08	21.35	< 0.0001
MET moderate	48.05	36.40	42.14
MET high	28.27	44.52	36.51
Predimed low	36.49	48.17	42.42	< 0.0001
Predimed high	63.51	51.83	57.58

HDL High density Lipoprotein. LDL Low density Lipoprotein. MET Unit of measurement of physical activity of the IPAQ questionnaire. Predimed Prevention Mediterranean Diet.

All the cardiovascular risk scales analyzed showed a decrease in mean values as the level of physical activity increased, and this was observed in both sexes. All the differences observed were statistically significant. Data are presented in Table 2.

Table 2

Mean values of the different cardiovascular risk scales according to physical activity by sex

	Women							Men
MET	Low		Moderate		High			Low		Moderate		High
	n	mean (SD)	n	mean (SD)	n	mean (SD)	p-value	n	mean (SD)	n	mean (SD)	n	mean (SD)	p-value
ALLY heart age	170	4.81 (9.11)	345	–0.91 (9.53)	203	–4.82 (6.44)	< 0.0001	141	8.16 (7.92)	269	6.51 (8.81)	329	1.60 (6.80)	< 0.0001
RALLY heart age	170	0.09 (0.19)	345	–0.04 (0.21)	203	–0.12 (0.15)	< 0.0001	141	0.17 (0.16)	269	0.13 (0.18)	329	0.03 (0.15)	< 0.0001
ALLY vascular age Framingham	160	4.49 (11.31)	326	–1.13 (10.83)	184	–5.71 (6.76)	< 0.0001	139	8.51 (9.81)	263	7.67 (11.19)	313	1.67 (7.69)	< 0.0001
RALLY vascular age Framingham	160	0.09 (0.23)	326	–0.04 (0.23)	184	–0.13 (0.15)	< 0.0001	139	0.18 (0.20)	263	0.15 (0.23)	313	0.03 (0.17)	< 0.0001
ALLY vascular age SCORE	127	3.93 (4.53)	219	2.84 (4.56)	129	1.31 (3.76)	< 0.0001	117	6.37 (6.64)	218	6.25 (6.57)	234	3.56 (5.17)	< 0.0001
RALLY vascular age SCORE	127	0.08 (0.09)	219	0.05 (0.09)	129	0.02 (0.08)	< 0.0001	117	0.12 (0.13)	218	0.12 (0.12)	234	0.07 (0.10)	< 0.0001
REGICOR scale	150	2.54 (1.72)	288	1.73 (1.54)	160	1.39 (1.06)	< 0.0001	131	3.44 (2.06)	250	3.39 (2.23)	281	2.46 (1.44)	< 0.0001
SCORE scale	127	0.43 (0.70)	219	0.32 (0.58)	129	0.11 (0.34)	< 0.0001	117	1.58 (1.43)	218	1.48 (1.74)	234	1.02 (1.27)	< 0.0001
DORICA scale	168	3.27 (2.87)	344	2.08 (2.35)	202	1.41 (1.49)	< 0.0001	141	7.01 (4.76)	268	6.78 (5.25)	327	4.56 (3.46)	< 0.0001
ERICE scale	160	3.02 (2.97)	326	2.41 (2.44)	184	1.88 (1.80)	< 0.0001	139	4.97 (3.49)	263	4.48 (4.48)	313	3.93 (3.32)	< 0.0001

ALLY Avoidable lost life years. RALLY. Ratio of Avoidable lost life years.

Something similar to that observed with physical activity can be seen with a heart-healthy diet, such that people, both men and women, who obtained high values in the questionnaire on adherence to the Mediterranean diet presented better values in all the cardiovascular risk scales, although the differences observed were not always statistically significant. Complete data are shown in Table 3.

Table 3

Mean values of the different cardiovascular risk scales according to healthy food by sex

	Women					Men
Predimed	Low		High			Low		High
	n	mean (SD)	n	mean (SD)	p-value	n	mean (SD)	n	mean (SD)	p-value
ALLY heart age	262	0.20 (9.39)	456	–1.16 (9.25)	< 0.0001	356	5.42 (8.16)	383	3.91 (8.32)	< 0.0001
RALLY heart age	262	–0.01 (0.21)	456	–0.04 (0.20)	< 0.0001	356	0.11 (0.18)	383	0.08 (0.18)	< 0.0001
ALLY vascular age Framingham	244	0.11 (10.80)	426	–1.71 (10.50)	< 0.0001	345	6.12 (9.92)	370	4.36 (10.03)	< 0.0001
RALLY vascular age Framingham	244	–0.01 (0.24)	426	–0.05 (0.22)	< 0.0001	345	0.13 (0.21)	370	0.09 (0.21)	< 0.0001
ALLY vascular age SCORE	169	2.67 (4.81)	306	2.34 (4.24)	ns	273	5.23 (6.30)	296	5.11 (6.09)	ns
RALLY vascular age SCORE	169	0.05 (0.10)	306	0.05 (0.09)	ns	273	0.10 (0.12)	296	0.09 (0.12)	ns
REGICOR scale	221	1.88 (1.45)	377	1.82 (1.59)	ns	319	3.05 (1.93)	343	2.97 (1.97)	ns
SCORE scale	169	0.28 (0.57)	306	0.26 (0.58)	ns	273	1.50 (1.52)	296	1.46 (1.53)	ns
DORICA scale	260	2.21 (2.27)	454	2.15 (2.44)	ns	355	5.99 (4.65)	381	5.70 (4.52)	ns
ERICE scale	244	2.24 (2.31)	4.26	2.20 (2.54)	ns	345	4.57 (3.92)	370	4.52 (3.84)	ns

ALLY Avoidable lost life years. RALLY. Ratio of Avoidable lost life years.

The prevalence of altered values of the cardiovascular risk scales (heart age, vascular age, REGICOR, SCORE, DORICA, and ERICE) decreased as the level of physical exercise increased; this situation can be observed in both men and women. All the data are presented in Table 4.

Table 4

Prevalence of altered values of the different cardiovascular risk scales according to physical activity by sex

	Women							Men
MET	Low		Moderate		High			Low		Moderate		High
	n	%	n	%	n	%	p-value	n	%	n	%	n	%	p-value
REGICOR scale moderate	150	13.33	288	4.17	160	0.63	< 0.0001	131	17.56	250	12.00	281	8.54	< 0.0001
REGICOR scale high		0.00		0.00		0.00			1.53		2.00		0
SCORE scale moderate	127	0.79	219	0.00	129	0.00	< 0.0001	117	6.11	218	6.03	234	5.98	< 0.0001
SCORE scale high		0.00		0.00		0.00			1.53		1.47		0.85
DORICA scale moderate	168	3.57	344	1.74	202	0.50	< 0.0001	141	17.73	268	16.52	327	8.26	< 0.0001
DORICA scale high		0.00		0.00		0.50			3.55		3.46		0.00
ERICE scale moderate	160	1.88	326	0.00	184	0.00	< 0.0001	139	12.95	263	10.07	313	4.79	< 0.0001
ERICE scale high-very high		0.00		0.00		0.00			0.00		1.52		0.00

MET Unit of measurement of physical activity of the IPAQ questionnaire.

The prevalence of elevated values of the cardiovascular risk scales also showed better results in people with a high adherence to the Mediterranean diet, with the differences found to be statistically significant in all cases, as shown in Table 5.

Table 5

Prevalence of altered values of the different cardiovascular risk scales according to healthy food by sex

	Women					Men
Predimed	Low		High			Low		High
	n	%	n	%	p-value	n	%	n	%	p-value
REGICOR scale moderate	221	5.43	377	5.17	< 0.0001	319	15.99	343	14.87	< 0.0001
REGICOR scale high		0.00		0.00			0.94		1.17
SCORE scale moderate	169	0.59	306	0.00	< 0.0001	273	5.64	296	5.44	< 0.0001
SCORE scale high		0.00		0.00			2.73		2.03
DORICA scale moderate	260	1.54	454	1.38	< 0.0001	355	15.21	381	13.91	< 0.0001
DORICA scale high		0.00		0.00			1.97		1.31
ERICE scale moderate	244	0.00	426	0.00	< 0.0001	345	8.70	370	7.81	< 0.0001
ERICE scale high-very high		0.00		0.00			0.87		0.27

Predimed Prevention Mediterranean Diet

In the multivariate analysis by binary logistic regression, the covariates established were male, aged 50 years or older, smoker, low or moderate physical activity, low adherence to the Mediterranean diet, and social classes II-III. Sex, age, and smoking were the only variables that showed an influence in all the scales analyzed. Of these, the one showing the greatest influence was age, with odds ratios ranging from 13.87 (95%CI 8.29-23.19) for moderate-high REGICOR and 66.34 (95%CI 21.89-121.54) for moderate-high risk ERICE. Physical activity and adherence to the Mediterranean diet showed no influence on any of the scales. All the results are presented in Table 6.

Table 6

Logistic regression analysis

	Men OR (CI 95%)	Age ≥50 years OR (CI 95%)	Tobacco consumption OR (CI 95%)	MET low-moderate OR (CI 95%)	Predimed low OR (CI 95%)	Social class II-III OR (CI 95%)
REGICOR scale moderate-high	3.29 (2.09–5.19)	13.87 (8.29–23.19)	3.80 (2.48–5.81)	2.32 (1.40–3.86)	ns	ns
SCORE scale moderate-high	44.93 (6.10–331.13)	56.15 (28.33–98.21)	3.79 (1.97–7.30)	ns	ns	ns
DORICA scale moderate-high	10.90 (5.85–20.34)	14.22 (8.46–23.90)	4.19 (2.65–6.60)	2.01 (1.21–3.32)	ns	ns
ERICE scale moderate-high	27.44 (8.22–91.58)	66.34 (21.89–121.54)	6.31 (3.46–11.51)	ns	ns	ns

MET Unit of measurement of physical activity of the IPAQ questionnaire.. Predimed Prevention Mediterranean Diet. ns Non significance

4 Discussion

The results of our study demonstrate that the mean values and prevalence of high values of the seven CVR scales analyzed are more unfavorable in people who do less physical exercise, in both men and women, and in all cases the differences are statistically significant. The effect of the Mediterranean diet, although it also improves all the CVR scales, is somewhat less intense and not always statistically significant.

All the studies we have reviewed are along the same lines as ours and show a beneficial effect of physical exercise on CVR scales. In the early years of this century, some authors [28] showed that regular physical activity decreased the risk of cardiovascular disease and that this benefit was inversely proportional to the level of physical activity performed and the level of physical capacity of the person.

The results of these early studies have been widely replicated and included in recent meta-analyzes, that have shown the association between prolonged television viewing and sitting significantly increases the risk of all-cause mortality in a curvy and straightforward way. Growing steadily and faster as television viewing time increased [29]. In a meta-analysis published in 2016, the authors obtained the same results, obtaining a higher risk (HR 1.14) in those people who sat longer (12.5 hours a day versus 2.5). In this same study, they found a significant increase in cardiovascular risk when sitting for more than 10 hours a day [30]. The protective effects of regular physical activity on cardiovascular risk occur in all ages, genders and races, regardless of whether the level of effort is low or high [31, 32].

A study of people aged 40 to 79 years using data from the 2003–2006 National Health and Nutrition Examination Survey in the United States assessed the relationship between physical activity determined with an ActiGraph 7164 accelerometer and the risk of suffering a first cardiovascular event in the next 10 years. The conclusion of the study was that the group that performed less physical activity had a higher risk probability of suffering a cardiovascular event. No differences were found between the two groups with higher levels of physical activity in terms of the risk of suffering a cardiovascular event [32].

Some studies have focused on the relationship between level of physical activity and the risk of developing coronary heart disease, indicating a clearly beneficial effect of physical exercise, such as Sattelmair who observed that individuals who performed 150 minutes/week presented a 14%decrease in risk while those who increased to 300 minutes/week presented greater decreases of approximately 20%. This suggests that performing a minimum of 150 minutes/week is sufficient to obtain significant cardiovascular benefits and that higher amounts provide additional benefits [33].

Regular physical activity is associated with a lower risk of CVD and its comorbidities. At the same time, physical inactivity is an independent risk factor for increasing the probability of suffering a cardiovascular event. Despite the known impact of physical activity and inactivity on CVD modulation, fewer than half of American adults achieved recommended levels of physical activity in 2011. The amount of inappropriate physical activity in leisure time is especially significant pronounced in individuals of low socio-economic level [34]. In our study, although the most disadvantaged social classes present worse results in cardiovascular risk factors, we did not find a significant association between physical exercise and increased cardiovascular risk in any of the models used.

There are also abundant studies in the scientific literature that relate diet to health, especially cardiovascular health, and many of these studies focus on the effect of the Mediterranean diet, as we have done.

Current evidence shows that healthy dietary patterns with a high intake of fiber, antioxidants, vitamins, minerals, polyphenols, monounsaturated and polyunsaturated fatty acids; low intake of salt, refined sugar, saturated and trans fats; and low-glycemic carbohydrates, support a greater magnitude of benefits than the potential effects of a single nutrient supplement, due to the synergistic health effects between them. The PREDIMED study, the largest interventional study on the Mediterranean diet, included 7447 subjects (55 to 80 years, 57%women) with high CV risk, without CVD at baseline, and showed a lower prevalence of CV events in participants assigned to a Mediterranean Diet. supplemented with extra virgin olive oil or walnuts than those assigned to a low-fat diet after five years of intervention, showing an absolute risk reduction of approximately three major cardiovascular complications per 1,000 person-years, which represents a reduction of approximately 30%in relative risk (RR) [35].

The Mediterranean diet can reduce the incidence of CVD by downregulating low-grade inflammation and better control of body weight, which also improve other risk factors and correlate with fewer clinical events [36]. The aforementioned studies show results that are in agreement with those obtained by us in this study.

We found different studies that assessed the relationship between cardiovascular risk and socio-demographic variables such as age, sex, and social class. In western countries, cardiovascular disease affects the most disadvantaged social classes much more, which leads to an unequal distribution of cardiovascular risk factors throughout society [37]. A cross-sectional study of 50254 workers in the Balearic Islands [38] aged between 20 and 65 years assessed the relationship between socio-demographic variables –such as age, sex, and social class –, and cardiovascular risk scales such as REGICOR and SCORE –revealing differences according to social class in most cardiovascular risk factors. These variations showed a differential pattern depending on age group and sex. Differences by social class in obesity in women increased with age, whereas they decreased in men. In all parameters, the worst values were found in the most disadvantaged social classes [38]. This study was carried out in a population similar to ours in terms of age and geographical area and obtained results superimposable to those obtained by us.

4.1 Strengths and limitations

Importantly, our study used a large sample size, the number of cardiovascular risk scales analyzed (specifically seven), and the fact that the assessment of physical activity and adherence to the Mediterranean diet was conducted with validated questionnaires (IPAQ and Predimed).

As limitations, it should be noted that our data are based on the Spanish population, so they cannot be extrapolated to other countries. When dealing with the working population, it excludes groups of unemployed people and students. In addition, only those patients who have attended company medical check-ups are included. Furthermore, it is known that people who perform physical activity on a regular basis and watch their diet tend to avoid tobacco and alcohol, which could be a confounding factor. Finally, as it is a cross-sectional study, it does not allow establishing causal relationships between the assessed factors.

5 Conclusions

This study reinforces the existing opinion that both diet and physical exercise decrease the probability of suffering a cardiovascular event and improve all the CVR scales analyzed herein: REGICOR, SCORE, DORICA, ERICE, heart age, Framingham vascular age, and SCORE vascular age.

Footnotes

Acknowledgments

None.

Author contribution

Conceptualization: AALG, PRS Data collection and analysis: SAB,TRF, NRF Methodology: JIRM, AALG Draft: JIRM, AALG Revision PRS, NRF, TRF, SAB.

Funding

None.

Conflicts of interest

The authors declare that they have no conflicts of interest.

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