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Diabetes & Metabolism
Vol 27, N° 4  - septembre 2001
p. 503
Doi : DM-09-2001-27-4-1262-3636-101019-ART11
Original articles

Influence of parental histories of cardiovascular risk factors on risk factor clusters in the offspring
 

V. Lascaux-Lefebvre [1], J.B. Ruidavets [1], D. Arveiler [2], P. Amouyel [3], B. Haas [2], D. Cottel [3], A. Bingham [4], P. Ducimetière [4], J. Ferrières [1]
[1] Department of Epidemiology, INSERM U558, Faculty of medicine, Toulouse, France.
[2] Department of Epidemiology, Faculty of medicine, Strasbourg, France.
[3] Department of Epidemiology, INSERM U508, Pasteur Institute of Lille, France.
[4] INSERM U258, Paul Brousse Hospital, Villejuif, France.

Abstract
Objectives

To assess the effect of parental histories of cardiovascular risk factors on risk factor clusters (RFC) in representative samples from three French populations (MONICA centers of Lille, Strasbourg, Toulouse).

Material and methods

In a representative cross-sectional study, we screened 1,291 males and 1,264 females, aged 35-64 years. Subjects were defined as RFC cases when they were affected by at least 2 disorders among, hypertension (systolic or diastolic blood pressure >= 140/90 mmHg and/or antihypertensive drug), diabetes (physician-diagnosed diabetes and/or glycemia >= 7.0 mmol/l and/or hypoglycemic drug), and dyslipidemia (triglycerides > 2.26 mmol/l and/or HDL-cholesterol < 0.9 mmol/l in men and < 1.2 mmol/l in women). Nineteen percent of the subjects were RFC cases. Parental histories of cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) were positive if they were under 65. About 29 % of the subjects had at least one parental history of risk factor.

Results

After adjustment for sex, age, educational level, sedentary lifestyle, alcohol consumption, body mass index, LDL cholesterol and center, parental histories of cardiovascular risk factors were significantly associated with the RFC. One, two, or at least three parental histories were significantly associated with increased odds of being RFC cases (adjusted OR 1.39 95 % CI [1.05-1.82], 2.90 95 % CI [1.91-4.40], 2.93 95 % CI [1.41-6.08]). Furthermore, a maternal-only history vs a paternal-only history of hypertension or diabetes was associated with strong odds of being an RFC case.

Conclusion

At least a single cardiovascular risk factor in parents was significantly associated with RFC in offspring, independently of environmental parameters.

Abstract
Antécédents familiaux et regroupement de facteurs de risque dans la descendance
Contexte

Evaluer l'association des antécédents familiaux de facteurs de risque cardiovasculaire (FRCV) et le regroupement des facteurs de risque dans la descendance à partir d'échantillons aléatoires de la population française (centres MONICA de Lille, Strasbourg et Toulouse).

Méthodes

Dans une étude transversale, nous avons examiné 1 291 hommes et 1 264 femmes âgés de 35 à 64 ans. Les sujets ont été définis comme des cas s'ils étaient affectés par au moins 2 FRCV parmi l'hypertension artérielle (pression artérielle systolique ou diastolique >= 140/90 mmHg et/ou traitement antihypertenseur), le diabète (diabète diagnostiqué par un médecin et/ou glycémie >= 7,0 mmol/l et/ou traitement hypoglycémiant) ou une dyslipidémie (triglycérides > 2,26 mmol/l et/ou HDL-cholestérol < 0,9 mmol/l chez les hommes et < 1,2 mmol/l chez les femmes). Dix-neuf pour cent des sujets étaient définis comme des cas. Les antécédents familiaux de FRCV (hypertension artérielle, diabète, hyperlipidémie) étaient considérés comme présents s'ils étaient découverts chez les sujets avant 65 ans. Environ 29 % des sujets avaient au moins un antécédent familial de FRCV.

Résultats

Après ajustement pour le sexe, l'âge, le niveau d'éducation, l'activité physique, la consommation d'alcool, l'indice de masse corporelle, le niveau de LDL-cholestérol et le centre, les antécédents familiaux de FRCV étaient significativement associés avec le fait d'être défini comme un cas. Un, deux ou au moins trois antécédents familiaux de FRCV étaient significativement associés à un risque accru d'être défini comme un cas (Odds ratio ajusté: 1,39 IC à 95 % [1,05-1,82], 2,90 IC à 95 % [1,91-4,40], 2,93 IC à 95 % [1,41-6,08]). De plus, les antécédents maternels par rapport à des antécédents paternels d'hypertension artérielle ou de diabète étaient associés avec un risque plus important d'être défini comme un cas.

Conclusion

La présence d'au moins un FRCV chez les parents est associée au regroupement des facteurs de risque dans la descendance indépendamment des facteurs de risque environnementaux.


Mots clés : regroupement de facteurs de risque. , antécédents familiaux. , facteurs de risque cardiovasculaire. , épidémiologie.

Keywords: risk factor clusters. , parental history. , cardiovascular risk factors. , epidemiology.


MATERIAL AND METHODS

During the last years, we could notice that hypertension, hyperlipidemia and diabetes cluster together and occurred more often than chance alone could explain [ [1], [2], [3]]. Several authors hypothesized a multiple metabolic syndrome or an insulin resistance syndrome characterized by the clustering of these cardiovascular risk factors [ [4], [5], [6], [7], [8], [9], [10], [11], [12]]. Familial aggregation of hypertension [ [13], [14], [15]], cardiovascular disease [ [16]], myocardial infarction [ [17]], non-insulin dependent diabetes mellitus (NIDDM) [ [18], [19], [20]], lipid disorders [ [21]] and obesity [ [22]] is well established. Genetic and shared environmental influences on insulin, insulin resistance and obesity have been reported [ [23], [24], [25]].

Appropriate studies are still needed to assess to what extent parental histories are involved in the aggregation of several risk factors in offspring, and especially in the French population where only few large cardiovascular epidemiological studies have been carried out. Few authors have studied the potential relationship between risk factor clusters (RFC) and parental histories. Actually, the majority of multivariate approaches of RFC were drawn in studies on families [ [25]] and twins [ [24], [26]]. Some authors have worked on familial components of the RFC and have shown that in a population survey concerning middle-aged adults, a strong association was found between parental history of hypertension and diabetes and the RFC in the offspring generation [ [27]].

The aim of this cross-sectional study was to determine whether one or several parental histories of cardiovascular risk factors were a risk factor for RFC after taking into account several environmental parameters. This study was carried out in 3 representative samples drawn from 3 French populations (the MONICA centers of the Urban Community of Lille, Bas-Rhin: Strasbourg, and Haute-Garonne: Toulouse), characterized by a low risk of cardiovascular disease [ [28]].

Population, sampling, study

A cross sectional study was carried out from December 1994 to April 1997. A sample of 1 660 males and 1 635 females aged 35-64 years was selected randomly in Lille (1 007), Strasbourg (1 124) and Toulouse (1 164). The samples were drawn from the polling lists available in each town hall. Subjects were screened for cardiovascular risk factors in a health center or at home. The participants were volunteers. Authorization from the appropriate Ethics Committees was obtained. The participation rate was 63.3 %.

Questionnaires

Each subject had to complete an informed consent form. With the help of specially trained medical staff, each subject filled in a questionnaire on his/her medical history, cardiovascular risk factors, drug intake, tobacco and alcohol consumption, lifestyle, occupational activity, educational level and socio-economic status. Participants were asked their parents' ages, and whether their parents had ever been diagnosed with hypertension, diabetes, and hyperlipidemia.

Clinical measurement

Height, weight, abdominal girth, hip circumference and blood pressure were measured according to standardized protocols. Two blood pressure measurements were made on the right arm with a standard mercury sphygmomanometer, the first one performed after a five-minute rest at least on participants in a sitting position. The body mass index (BMI) was calculated.

Blood sample collection and biological analysis

A blood sample was taken after a minimum fasting period of 10 hours, kept in tubes at room temperature and centrifuged within 3 hours. Serum tubes were stored at - 80 °C temperature. All biological analyses were performed at a central laboratory and lipid parameters were analyzed two weeks after the blood sample had been taken. Serum total cholesterol and triglycerides were measured by enzymatic method. High-density lipoprotein (HDL) cholesterol was measured in the supernatant after phosphotungstate/magnesium chloride precipitation. Low-density lipoprotein (LDL) cholesterol was determined by Friedwald formula. Fasting blood glucose was measured with a hexokinase-glucose-6-phosphate dehydrogenase method.

Study design
Parental histories of risk factors

Several types of parental history variables were derived from the family history questionnaire. Firstly, the number of cardiovascular risk factor histories among both parents (hypertension, diabetes, hyperlipidemia) were added and ranged from zero to five (five, because no subject had both parents affected by the three disorders), whatever the type of disorder. Secondly, we studied the influence of each risk factor, alone or combined. Thirdly, we examined the parental role and the cumulative effect when both parents were affected. A parental history of cardiovascular risk factors before the age of 65 was considered positive. This limit was the third quartile of the distribution of the ages of parental histories. Subjects who ignored at what age their parents' risk factors had been diagnosed, were compared and excluded.

Risk factor clusters in the offspring

Hypertension, dyslipidemia and diabetes in the offspring were regarded as components of the RFC. The definition of hypertension was systolic blood pressure >= 140 and/or diastolic blood pressure >= 90 mmHg and/or when antihypertensive drugs were prescribed [ [29]]. The definition of diabetes was: physician-diagnosed diabetes and/or fasting glycemia >= 7.0 mmol/L (1.26 g/l) and/or the use of hypoglycemic medication. The definition of dyslipidemia was: having triglycerides >= 2.26 mmol/l and/or cholesterol-HDL < 0.9 mmol/l in men and < 1.2 mmol/l in women [ [30]]. RFC cases were validated when at least two of the three clinical disorders were present.

Environmental parameters

Women were considered as the referent sex category. Two educational levels were defined: one for subjects under or equal to high school diploma level and the other for subjects above high school diploma level (reference). Sedentary lifestyle was defined according to leisure time physical activity: none or moderate (light physical activity less than 20 minutes a week), versus vigorous physical activity (reference). Alcohol consumption was expressed in grams of alcohol per day. Three levels of alcohol consumption were identified: the first corresponding to teetotallers (reference), the second, less than 40 grams of alcohol per day and the third more than 40 grams of alcohol per day.

Statistical Methods

Data were analyzed with SAS statistical software (version 6.10). The results for each variable were expressed in the tables in arithmetic forms. Since all the variables were qualitative, between-group comparisons were made using chi-square tests. Logistic regression models were done for the dichotomous dependent variable. RFC cases (n = 490) were contrasted with disorder-free and one disorder control subjects (n = 2065). A p value < 0.05 was considered statistically significant.

RESULTS

Approximately 24 % (n = 786) of the subjects had one or several parental histories with unknown age of discovery and were excluded from the analysis. Thus, the sample of our study was composed of 2 555 subjects, 1 291 men and 1 264 women. The RFC cases represented 19.2 % of the population.Table I

depicts the characteristics of the RFC cases and controls. Men were more often affected by the RFC than women. RFC cases tended to be older, had a more sedentary lifestyle, a lower educational level and an alcohol consumption >= 40 grams per day, than controls, and were more likely to have multiple parental histories.Table II

shows the association between parental histories of cardiovascular risk factors and the RFC. One, two or at least three parental histories were associated with increased odds of being a RFC case (OR 1.39 95 % CI [1.05-1.82], 2.90 95 % CI [1.91-4.40], 2.93 95 % CI [1.41-6.08]), adjusted for sex, age, educational level, sedentary lifestyle, alcohol consumption, BMI, LDL cholesterol and center.Table III

shows the association of parental histories of single and combined cardiovascular risk factors with the RFC. Compared to controls, RFC cases were more likely to have one or two parental histories of hypertension (OR 1.88 95 % CI [1.44-2.46]) or hyperlipidemia (OR 1.79 95 % CI [1.25-2.57]) or diabetes (OR 1.76 95 % CI [1.24-2.49]). Any combination of one or more parental disorders was associated with increased odds of RFC, especially the combination parental histories of hypertension or diabetes (OR 1.84 95 % CI [1.44-2.35]).Table IV

shows the results focusing on parental histories of hypertension, diabetes and hypertension and/or diabetes, with regard to differences in maternal vs paternal history. RFC cases were more than twice as likely to have two hypertensive parents and more than three times as likely to have two hypertensive and/or diabetic parents than controls. A maternal-only history of hypertension or diabetes was associated with strong odds of being an RFC case than a paternal-only history. Odds ratios differed but confidence intervals overlapped.

DISCUSSION

Our results showed that there was a significant relationship between a reported parental history of cardiovascular risk factors and adult offspring's RFC status, after adjustment for numerous confounding factors. The relationship depended on the number of parental histories. We observed a dose-response relationship between the number of parental disorders and the odds of having RFC. The risk of the RFC increased when both parents were affected. Moreover, the relationship depended on the sex of the affected parent. The association between the RFC and maternal history was stronger, when compared to paternal history. This result is consistent with the findings of the CODIAB study [ [20]]. However, some authors concluded that reporting bias might partly account for some of the discrepancies in previous results [ [31]]. In fact, women tended to have better knowledge of their own and family's health status and reported their chronic diseases more frequently than men [ [32]]. Also, our results are interesting since the relationship was observed when parental histories were diagnosed before the age of 65 years. We found similar results for parental histories before the age of 60, and even before the age of 55 (data not shown).

While many metabolic impairments have been proposed as components of the multiple metabolic syndrome [ [6], [8], [10], [33]], to our knowledge, no suggestion has ever been made concerning which disorders and how many, are needed to determine a multiple metabolic syndrome. In agreement with Liese

et al.

[ [27]], we chose hypertension, diabetes and dyslipidemia, defined by hypertriglyceridemia and low HDL-cholesterol, for their clinical relevance. We also chose low values for the definition of the disorders (blood pressure 140/90 mmHg; glycemia 7.0 mmol/l) to study an early occurrence of RFC. However, the results obtained with higher thresholds (blood pressure 160/95 mmHg; glycemia 7.85 mmol/l) were similar (data not shown). Our results also showed a strong statistically significant association between parental histories of cardiovascular risk factors such as hypertension, diabetes, hyperlipidemia and the RFC. Some authors used the same definition of the RFC (hypertension, diabetes and dyslipidemia) in a study of male twins [ [24]]. Their findings suggested the presence of an underlying genetic factor. They also suggested that the clustering phenomenon was mediated by a common latent factor, influenced both by environmental and genetic factors. Other authors suggested a concept of a common gene or a set of genes (pleitropy) [ [25]]. Some studies justified the concept of studying the joint contribution of parental histories of hypertension and diabetes [ [34], [35]]. Our findings showed that parental history of hypertension might induce higher risk of RFC than parental history of diabetes or hyperlipidemia, both individually and as part of a cluster of parental histories. These findings should be interpreted with caution given the drawbacks related to self-report, especially for hypertension. The accuracy of the reports of parental history of hypertension can be biased, as it was observed in a study in which the authors compared 292 undergraduates' reports on their parents' histories with the parents' reports [ [36]].

Some limitations of this study should be mentioned. The parental history information was based on the participants' reports and exposed to a recall bias. But this bias was probably weak because some authors have already studied the accuracy of parental history information and suggested that neither misclassification nor recall bias had a substantial impact on the measurement of the effect of the family history [ [37]]. In our study, the parental history was based on the report of the age of discovery of cardiovascular risk factors in parents, and approximately 24 % of the subjects reported that the age of diagnosis was unknown. This could result in an information bias since some authors showed that anamnestic data led to an overestimation of positive parental history [ [38]]. Thus, a misclassification of parental history may have occurred. This is the reason why the subjects who where uncertain about their parents' histories were excluded from the analysis. However, we tested the same logistic models including these subjects, and the results were similar to those which excluded them; after full adjustment, one or more parental histories of cardiovascular risk factors in subjects who reported that the age of discovery of cardiovascular risk factors in parents was unknown were associated with increased odds of being RFC case (OR 1.88 95 % CI [1.46-2.42], p < 0.0001) whereas one, two and at least three parental histories before the age of 65 had the same association with RFC status (OR 1.32 95 % CI [1.01-1.72], 2.16 [1.59-2.93], 2.78 [1.51-5.14]) as in previous models. Furthermore, in a previous study, we have shown that a parental history of hypertension was a reliable factor associated with offspring's hypertension [ [39]].

In conclusion, strong and significant relationships were shown between parental history of cardiovascular risk factors under 65 and the RFC in offspring, independently of confounding parameters. A single parental history was associated with the RFC, and the risk increased with the number of parental histories. Furthermore, the risk of RFC was higher with maternal-only history and with parental history of hypertension. Our study shows the relevance of an investigation of parental history of cardiovascular risk factors during medical examinations. It also suggests that the determination of plasma glucose and lipid levels, in case of parental history of cardiovascular risk factors, might be of interest in current medical practice.Acknowledgements

The authors would like to thank the Centre d'Examen de Santé de Strasbourg for its logistic support. The WHO-MONICA population study developed in France was supported by grants from the Conseil Régional du Nord-Pas de Calais, the Caisse Primaire d'Assurance Maladie de Sélestat, the Association Régionale de Cardiologie d'Alsace, ONIVINS, Parke-Davis Laboratory, the Mutuelle Générale de l'Education Nationale (MGEN), the Réseau National de Santé Publique, the Direction Générale de la Santé, the Institut National de la Santé et de la Recherche Médicale (INSERM), the Institut Pasteur de Lille, and the Unité d'Evaluation du Centre Hospitalier et Universitaire de Lille.

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