Skip to main content
Download PDF

Physical activity and odds of coronary heart disease among Lebanese women

BMC Public Health volume 24, Article number: 516 (2024) Cite this article

Abstract

Background

It is known that physical activity (PA) is protective against cardiovascular morbidity and mortality. However, few studies have examined the association between PA, sedentary lifestyle and coronary heart disease (CHD) in women. This case–control study investigates the relationship between PA and sedentary behavior on CHD odds in Lebanese women over forty.

Methods

One thousand five hundred selected Lebanese women (300 cases and 1200 controls) were included between 2018–2019. Cases were hospitalized women newly diagnosed with CHD, whereas the control groups were free of any heart diseases. Data on socio-demographic, lifestyle, cardiovascular factors, PA and sedentary lifestyle were collected. Multivariate logistic regressions, adjusted for covariates, were performed to investigate the association of PA domains and sedentary behavior with CHD.

Results

A sedentary lifestyle combined with low activity levels increased the odds of CHD. Among cases, 46.7% participated in moderate or vigorous PA against almost 60.3% of controls. 36.3% of coronary patients had more than 10 h/day of sedentary time, with a positive correlation with CHD (adjusted OR: 1.533, 95%CI: 1.046–2.247). Conversely, moderate and high levels (respectively 600–3000 and ≥ 3000 metabolic equivalents [MET]-minutes/week) of domestic/garden PA revealed lower CHD odds (OR: 0.566, 95%CI: 0.396–0.808 and 0.193, 0.065–0.578 respectively). The detrimental influence of sedentary lifestyle appeared to be significantly reversed by weekly moderate PA, especially as weekly sedentary time was less (OR: 0.616, 95%CI: 0.427–0.888/ 6 to10h of sedentary time and OR: 0.537, 95% CI: 0.37–0.779/ ≤ 6 h), and except sedentary time exceeding 10 h daily. Two PA patterns revealed lower CHD odds: transport-related and domestic/garden PA, as early as low amount, even after adjustment for possible confounders.

Conclusion

The current study highlights the importance of combating sedentary behaviors and engaging in regular, easily accessible PA to reduce the odds of coronary disease among aging women. Therefore, better information regarding the benefits of physical activities such as transportation-related activities or gardening would be helpful in enhancing the prevention of CHD in aging women.

Peer Review reports

Introduction

Physical activity (PA) is recognized by the American Heart Association as an independent protective factor against coronary heart disease (CHD) [1]. In particular, PA can help lower blood pressure, maintain normal glucose tolerance and improve lipid balance [2], thereby reducing the risk of developing CHD [3]. Although PA is cardioprotective, different patterns of PA have different benefits for cardiovascular disease (CVD) prevention [4,5,6]. While CHD was responsible for more than 9 million deaths worldwide in 2019, and though CVD mortality has decreased in recent decades in Western countries, especially due to improved diagnostic and preventive methods, CHD continues to increase in developing countries, due to globalization and the adoption of more Western lifestyles [7, 8]. In Lebanon, CHD accounts for nearly 47% of total annual deaths [9].

Lack of PA has been identified as the fourth leading risk factor (RF) for global mortality and one of the leading public health indicators [10]. Physical inactivity is an important RF for CHD [11] and is the highest in high-income countries. Nowadays, high levels of physical inactivity are also observed in some middle-income countries, particularly among women [12].

It is known that physically active women seem less likely to develop CHD compared to inactive women [13,14,15]. However, in most countries, women are less active than men [16] and a third of women do not engage in leisure-time PA [3]. PA levels appear to decrease progressively after 65, with a greater decline among women [17]. Otherwise, sedentary time was associated in a dose–response relationship with an increased cardiovascular risk. On average, each additional hour of sedentary time in older women was associated with a 26% increase in adjusted CHD risk [18]. Replacing sitting with moderate or vigorous PA may be associated with reduced CVD mortality risk [19].

While women have CHD that is sometimes difficult to identify quickly (i.e., myocardial infarction/ischemia syndromes with no obstructive coronary artery disease (MINOCA/INOCA)) [20, 21], which may lead to a delay in their management and an unfavorable impact on their prognosis compared with men, few studies have focused on specifying the intensity and profile of PA that could be useful in preventing CHD in women.

According to the World Health Organization (WHO), currently 42% of Lebanese women are physically inactive [22], thus constituting a major public health problem [23].

The aim of our study is to identify the PA and sedentary pattern of Lebanese women in order to determine a potentially useful profile for the prevention of CHD in women.

Methods

Study design

The inclusions were performed from December 2018 to December 2019 in hospitals based in Beirut and Mount-Lebanon regions (Military Hospital, Makassed Hospital, Sacred Heart Hospital, Lebanese Geitaoui Hospital, Rafik Hariri University Hospital, and Mount-Lebanon Hospital).

We included, as previously described [24], 300 women aged 40 years and older, with a primary diagnosis of CHD in the cardiology service, following a myocardial infarction (MI) with or without ST-segment elevation or stable/unstable angina; diagnoses confirmed by a cardiologist based on their clinical presentation and paraclinical data. The case group had no history of heart disease (MI, CHD, valvular heart disease, cardiomyopathy, and myocarditis). For each case, four controls aged ≥ 40, matched by hospital, were randomly selected from surgical and general medicine wards, constituting a control group of 1200 patients (excluded were patients with a history of CHD, pregnant patients, or those suffering from cancer or mental disorders). Informed consent was obtained from each patient included, after validation of the protocol by the ethics committee of each hospital.

Calculation of total enrollment (n = 1500) was done by estimating the minimum sample size that would be necessary to show a twofold increase in CHD odds, in a case–control ratio of 1/4, based on CHD prevalence in Lebanese women older than 40 years (9%) [25], an alpha error of 5%, and a study power of 80% (Epi Info™).

Data collection

After analysis of the medical records, allowing the collection of certain sociodemographic (age, weight, height) and medical (medical treatments, biological and paraclinical data) information, a face-to-face interview by the investigator was carried out.

We collected socio-demographic elements (residence area, educational level (low: illiterate or primary school; middle: complementary or secondary school; high: university level), marital status, professional status, monthly income), factors related to patients’ health, particularly cardiovascular: age, menopausal status, smoking (assessed based on tobacco, cigarette or waterpipe consumption (current smoker (smoked in the last 12 months), non-smoker and former smoker (quit smoking more than a year earlier))) [1, 26], RFs for CHD based on patient self-reported, current use of medications and/or laboratory test results when available: (hypertension (≥ 140/90 mmHg), dyslipidemia (non-HDLc (non-High-Density Lipoprotein Cholesterol) ≥ 3.4 mmol/L, triglycerides ≥ 1.7 mmol/L or LDLc (Low-Density Lipoprotein Cholesterol) ≥ 3 mmol/L [27], diabetes (random blood sugar ≥ 11.1 mmol/L or glycated hemoglobin ≥ 6.5% [28]), body mass index ((BMI), overweight: BMI of 25 to 29.9 kg/m2, obesity: BMI ≥ 30 kg/m2) [12], lifestyle factors (alcohol consumption (consumption of any alcoholic beverage within the previous 12 months) [29], diet). Eating habits were assessed using the Lebanese Mediterranean Diet Score (LMDS) (scores from 0 to 80 (best nutritional quality score)) [30]. Depression was assessed using the Beirut Distress Scale (BDS-22) (score from 0 to 66 (maximum psychological distress)) [31].

Physical activity

PA was assessed using the International Physical Activity Questionnaire (IPAQ) long form version [32].

Total PA was calculated by giving each type of activity by its estimated energy requirements: 3.3 metabolic equivalent task (MET) for walking; 4 for moderate-intensity and 8 for vigorous PA (during work or leisure); 6 for cycling (transport); 4 and 5.5 for moderate- and heavy-intensity garden work, respectively; and 3 for moderate-intensity housework. Thus, the total PA score was obtained by multiplying the MET score by the minutes performed in a week for all types of activities in all domains (work, transportation, housework/gardening, leisure). A woman was considered moderately active for a score of 600 to 3000 MET-min/week combining all types of activities (equivalent to 5 or more days of moderate-intensity activity and/or walking of at least 30 min per day; or 20 min of vigorous activity 3 days per week, or a combination of both), and physically very active if the score was ≥ 3000 MET-min/week. A woman was classified as low active or inactive if she did not meet any of these criteria.

Sedentary time was further determined as the time reported to be at rest, other than sleep (such as sitting during transportation, work, or leisure, watching television, using a computer or cell phone) [33].

Data analysis

Data were analyzed using SPSS version 21. Categorical variables are expressed in frequency and percentages, continuous variables in mean and standard deviation. Pearson’s chi-square test assessed the association between the different independent variables and the dependent variable (CHD status). Means were compared using the Independent Samples T-test. Patients were classified according to a minimum level of PA, with at least 600 MET-min/week defining a "physically active" status. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Multivariate logistic regression, using the enter method, assessed the association of PA domains and sedentary behavior with CHD, adjusted for covariates. To reduce the potential for multicollinearity, the domains of PA and sedentary time were entered as independent variables in the first block of the analysis and the other variables in the second block. Each variable having a p-value < 0.2 in the bivariate analysis was included in the models. The final model was accepted after checking the adequacy of the data using the Hosmer–Lemeshow test.

Results

Socio-demographic characteristics by CHD status

The baseline characteristics of the study population are presented in Table 1. Compared with controls, CHD women were significantly older (65.46 ± 10.33 years vs 62.36 ± 12.44 years, p < 0.001), lived more in the capital Beirut, in urban areas (28% vs 22.3%, p < 0.01), were unmarried (50.3% vs 43.8%, p < 0.05) and had a lower educational level (47.3% vs 36.8%, p < 0.01).

Table 1 Baseline socio-demographic characteristics of study population
Full size table

Health characteristics by CHD status

Table 2 shows the health-related characteristics of the study population. The postmenopausal status seemed to be associated with CHD in women (94% vs 85.5% in coronary cases and controls, respectively, p < 0.001). Patients with CHD had also more cardiovascular RFs compared to controls (hypertension (91.3% vs 68.4%, respectively, p < 0.001), dyslipidemia (78% vs 48.7%, respectively, p < 0.001) and diabetes (54% vs 36.5%, respectively, p < 0.001)).

Table 2 Health related characteristics of study participants
Full size table

Regarding lifestyle habits, smoking, which involves more than 44% of the study patients, was significantly higher among coronary cases (54.7% vs 41.6%, respectively, p < 0.001); in addition to the non-adherence to a healthy Mediterranean diet (39.53 ± 5.64 vs 40.30 ± 5.08, respectively, p < 0.05) and psychological distress (12.85 ± 15.86 vs 10.88 ± 13.65, respectively, p < 0.05).

It is interesting to note that cases also suffered significantly more from common joint pain (very frequent in our sample (59%) and likely to discourage PA) (70% vs 56.3%, respectively, p < 0.001).

PA and coronary odds

We studied the PA pattern (intensity and domains) in our study’s patients (Table 3).

Table 3 Physical activity rates and coronary heart disease odds according to different types and domains of physical activity
Full size table

53.3% of hospitalized patients with newly diagnosed CHD reported no or low PA before hospitalization, whereas 60.3% of patients in the control group engaged in at least moderate activity (OR = 0.575 [0.446–0.742], p < 0.001). While walking or vigorous PA did not appear to be significantly different between CHD patients and controls, moderate PA appeared to be associated with significantly reduced odds of developing CHD with a graded response to weekly practice duration. Half of the coronary cases (50.3%) were involved in less than 60 min/week of moderate-intensity activity, while 53% of the controls were engaging in more than 180 min/week of such activity. Women practicing moderate activity for 60–180 min/week or more than 180 min/week were less likely to be at risk than those who practiced less than 1 h/week (OR = 0.658 [0.441–0.983], p < 0.05, and OR = 0.472 [0.358–0.621], p < 0.001, respectively).

Concerning the PA domains, activities inherent to the work do not seem to be very different. Similarly, leisure-time PA did not appear to differ significantly between the two patient groups. On the other hand, PA for transportation and domestic or gardening work seemed significantly different between the 2 groups. Over 15% of non-coronary women were engaged in moderate transportation-related PA (600–3000 MET-min/week), compared with 6% of coronary women, representing a 64.9% reduction in the associated CHD threat (OR = 0.351 [0.212–0.579], p < 0.001). In addition, a 'dose–response' relationship in household or gardening activities was also associated with a reduced odds of CHD in active women: 30.7% of cases vs 45.3% of controls practiced this type of activity at moderate amount (600–3000 MET-min/week), and 1.3% of cases vs 6.1% of controls at high amount (≥ 3000 MET-min/week), thus protecting 51.7% and 84.3% against CHD (OR = 0.483 [0.368–0.635]; and 0.157 [0.057–0.434], p < 0.001, respectively).

Sedentary lifestyle and PA

We assessed the sedentary profile of our study’s patients (Fig. 1A). The total daily sedentary time (in minutes/day) emerged significantly different between the two groups, on weekdays and weekends (524 ± 206 vs 484 ± 204, p < 0.01 and 529 ± 205 vs 486 ± 202, p = 0.001, respectively); essentially corresponded to substantially more leisure time spent sitting on weekdays (347 ± 219 vs 297 ± 200, p < 0.001) and weekends (344 ± 219 vs 298 ± 198, p = 0.001) in coronary patients compared with controls (Fig. 1A, left). In contrast, controls tended to spend more time sitting at work during the week (30 ± 75 vs 22.52 ± 60, p = 0.049).

Fig. 1
figure 1

Sedentary in study participant. A Sedentary time and domains of sedentary in study participants. Average time (minutes/day) reportedly spent sitting in each domain on a usual weekday and weekend day (left) and in front of a screen over the week (right) among coronary and control women. aScreen represents the sum of TV-viewing and PC or phone-using. B Comparison between controls and coronary cases for the total sedentary behavior time (minutes/day) during the week. C Scatter plot for the relationship between sitting time (minutes/day) and physical activity (MET-minutes/week). Pearson’s correlation coefficient = -0.580 (P < 0.001). *p-value ≤ 0.05, **p-value ≤ 0.01, ***p-value ≤ 0.001

Full size image

Note that the domain usually taken as a reference to assess sedentary time (screen time) did not appear significant between coronary women and controls if total screen time was measured (Fig. 1A, right). A total of 36.3% of coronary women spent more than 10 h a day sitting during the week (weekdays and weekends), compared with 24.8% of non-coronary women (Fig. 1B), which could increase their odds of developing CHD.

An inverse significant correlation was found between PA level and reported sedentary time in the women studied (Pearson coefficient = -0.580, p < 0.001) (Fig. 1C).

PA, sedentary lifestyle and coronary odds

The summary ORs for the joint associations of sitting time and total PA with CHD odds are shown in Fig. 2. A clear dose–response association was observed, with an increased odds of CHD with increasing sitting time in combination with lower activity levels (Fig. 2A and B). Compared with those engaging in high total PA and having the least sedentary lifestyle (sitting ≤ 6 h/day), patients having moderate PA and low PA levels were more likely to be in the CHD group, with increasing odds as the sedentary time increases (Fig. 2B), suggestive of the impact of prolonged sitting on PA on CHD development. Of note, very few women in our study practiced weekly PA of ≥ 3000 MET-min/week.

Fig. 2
figure 2

Odds ratio of daily sedentary associated with weekly PA and the odds of CHD. A, B Sedentary and total PA; C, D. Sedentary and duration of total PA of moderate intensity. A, C Schematic representation of ORs with 95%CI. B, D Table including the numerical values of the ORs (95%CI). The reference category is the best condition group: lowest levels of sedentary (≤ 6 h/day) and higher weekly total PA (≥ 3000 MET-min/week) (A, B), lowest levels of sedentary (≤ 6 h/day) and higher weekly duration of moderate-intensity PA (≥ 180 min/week) (C, D). PA: physical activity, OR: Odds ratio, CI: Confidence interval, MET: metabolic equivalent task, CHD: coronary heart disease. *p-value ≤ 0.05, **p-value ≤ 0.01, ***p-value ≤ 0.001

Full size image

Also, we specifically assessed the association between weekly moderate-intensity PA duration, sedentary time, and coronary odds (Fig. 2C and D): weekly moderate-intensity PA of 1 to 3 h was accompanied by an increased odds of CHD with a daily sedentary time greater than 10 h (Fig. 2C) (OR = 2.178 [1.095–4.335], p < 0.05) (Fig. 2D). Below 1 h of weekly moderate PA, the odds of CHD was significantly increased regardless of the sedentary time level (Fig. 2C and D), but more so the higher the daily sedentary time (OR = 2.200 [1.050–4.611], p < 0.05; OR = 2.239 [1.474–3.401], p = 0.001; OR = 2.342 [1.623–3.379], p = 0.001, respectively for increasing duration of sedentary time) compared with a moderate PA level of at least 3 h in a woman spending less than 6 h per day sitting. (Fig. 2C and D).

In contrast to these results, the detrimental influence of sedentary lifestyle on coronary odds appeared to be reversed by weekly PA of moderate frequency and duration (600–3000 MET-min/week), especially as sedentary lifestyle was less (OR = 0.616 [0.427–0.888], p = 0.01; OR = 0.537 [0.37–0.779], p = 0.001, respectively for sedentary time of 6 to 10 h and ≤ 6 h weekly) and as soon as sedentary time did not exceed 10 h daily (OR = 0.922 [0.433–1.962], ns) (Fig. 3A and B).

Fig. 3
figure 3

Odds ratio of daily sedentary associated with weekly total PA level and the odds of CHD. A Schematic representation of ORs with 95%CI. B Table including the numerical values of the ORs (95%CI). The reference category is the group with the highest levels of sitting time (> 10 h/day) and lowest total PA (< 600 MET-min/week). PA: physical activity, OR: odds ratio, CI: confidence interval, MET: metabolic equivalent task, CHD: coronary heart disease. *p-value ≤ 0.05, **p-value ≤ 0.01, ***p-value ≤ 0.001

Full size image

The odds of CHD (adjusted OR and 95%CI) in women associated with PA domains and sedentary time was assessed in different models: after adjustment for sociodemographic factors (model 1), further combining adjustment for joint pain, and depression (model 2), and finally adjusted for smoking, LMDS, and biological RFs (model 3) (Table 4).

Table 4 Association between domains related physical activity, sedentary time and CHD among women
Full size table

Leisure-time PA and vigorous transportation-related PA were associated with decreased but non-significant odds of CHD. In contrast, moderate transportation-related PA was correlated with a significant decrease in the odds of CHD in model 1, and remained statistically significant after adjustment for sociodemographic, lifestyle, and cardiovascular RFs (model 3) (OR = 0.426 [0.247–0.734], p = 0.002, compared with low PA in the context of transportation.

PA related to housework or gardening was associated with a significantly lower odds of CHD, with a substantial reduction of 43.4% and 80.7% observed for moderate- (600–3000 MET-min/week) and high-PA (≥ 3000 MET-min/week), respectively, compared with those with little or no exercise. In contrast, women who sat for long periods of time (> 10 h/day) had a significant increase of approximately 53.3% in the odds of CHD (OR = 1.533 [1.046–2.247], p = 0.029) compared with those sitting less than 6 h/day.

Discussion

To our knowledge, our study is the first to assess the relationship between PA and odds of CHD in Lebanese women. It is also the first to provide a unique insight into the different patterns of PA and sedentary behavior in Lebanese women with CHD. Essentially, our results showed that women who practice at least moderate-intensity PA, both in transportation and in conventional activities of daily living, appeared to be protected against CHD. On the other hand, a significant sedentary lifestyle in women, more than 10 h of daily sitting, was associated with an increased odd of CHD.

The rapid sociodemographic transition in developing countries has introduced substantial lifestyle changes that have been largely characterized by increasing prevalence of obesity and physical inactivity [34] and consequently increasing risk of CVD [8]. In general, low or declining PA levels often correspond to high or rising gross national product [3, 16].

The prevalence of physical inactivity among women in our study (42.4%) was very close to that of non-communicable diseases (41.7%) published in 2010 by WHO. This result was consistent with other studies showing that most women in Arab countries suffer from insufficient PA, for example, 76.2% in Saudi Arabia, 72.1% in Kuwait, 68.9% in the Emirates, 47.6% in Mauritania, 54% in Iraq, and 40.3% in Tunisia [12, 35].

We did not find a significant protective association of leisure-time PA or high-amount transport PA with CHD, which is puzzling compared with the literature [36, 37]. This could be explained by the low prevalence of high-amount PA for transport in our population, possibly due to the predominance of hot, sunny weather limiting this type of activity. In addition, there is a barrier related to the lifestyle habits, most of the women live in urban/peri-urban areas (Beirut and Mount-Lebanon), thus with a lack of green spaces for regular PA practice, and Lebanese women are generally not accustomed to using gyms, as demonstrated in Polish women who do not practice enough during their leisure time [38]. However, moderate PA in the transport setting resulted in a substantial reduction in the odds of coronary events among women studied, a result consistent with previous studies [13, 15] showing that intense activities were not necessary to reduce the rate of CHD in women.

Work-related PA did not appear to be associated with CHD in our study, in line with the results of a previous study [39], which is quite old, but perhaps consistent with the low proportion of working women in our study (144 patients (9.6% of the total number), of whom only 21 were CHD patients (1.4%)), and on the other hand infrequently in physically demanding jobs. However, it should be noted that previous research had not suggested a greater potential protective benefit for vigorous-intensity PA [4], moreover, intense occupational PA could be detrimental to health [40, 41].

Previous study suggested that sitting for 10 or more hours per day was associated with increased odds of CVD [42] and mortality, but at least moderate PA could reverse this adverse effect [19]. However, sedentary behavior is not simply the absence of PA. Individuals may engage in PA while otherwise spending a lot of time sitting [43]. In our study, women with CHD had significantly more sedentary time than controls, including after adjustment for confounders. We note the protective role of various household and/or gardening activities on CHD. These results are interesting, because domestic activity remains the main contributor to daily PA, especially in the elderly [44]. These findings are consistent with previous studies showing that home-based activity has health benefits, by reducing cardiovascular mortality [5, 45] and CHD risk [5]. Gardening can, moreover, be discussed as an integral part of the "Mediterranean diet" combining an omega-3 and vitamin rich, protective dietary culturally adopted in Mediterranean countries (which our patients present), and outdoor moderate daily PA, favoring vitamin D synthesis, seasonal adaptation to light, consumption of mature fruits and vegetables; this combined strategy improves women’s health [46].

One study noted that PA related to housework was not associated with a reduced odd of CVD [47], but the mean age was lower (52.4 years) and the assessment was for intense domestic PA only. Although retired or unemployed women were less likely to participate in PAs during their leisure time, they appeared to spend more time on housework, as shown in Brownson’s study [48].

Thus, our results in Lebanese women are consistent with recent European Society of Cardiology (ESC) guidelines recommending adults of all ages to strive for at least 150–300 min a week of moderate-intensity PA [49], and could be used in a pragmatic CVD prevention strategy in aging Lebanese women, as has been considered for other countries [50].

Our study has some limitations. The sample was composed of hospitalized patients from 2 regions and therefore may not represent a balanced distribution of the overall population. However, to minimize the selection bias effect, controls were selected from the same hospital as the cases. Self-reported PA likely has a significant measurement error [51], which may lead to underestimate the influence of PA on CHD odds. Although we performed a multivariate analysis, the possibility of residual confounding by unmeasured factors remains. However, the large sample size and face-to-face interviews increased the precision of the study. The use of incident cases also avoids survival bias. In addition, the assessment of all domains of daily PA enhances reflection on the outcomes. Furthermore, we collected detailed information on demographic, socioeconomic, and health factors, which allowed adjustment for these important confounders.

Conclusion

Our results highlight the cardiovascular health benefits of PA in preventing CHD odds in Lebanese women, even while spending several hours sitting. As urbanization continues, promoting the potential benefits of easily accessible PA could be an important public health message for aging women who do not participate in PA in a sports club setting. Thus, actions to raise women’s awareness through the commitment of dedicated government policies could promote the virtuous couple: a Mediterranean diet associated with regular PA, accessible and adapted to the female population in developing countries for the benefit of their cardiovascular health.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

BDS:

Beirut Distress Scale

BMI:

Body mass index

CHD:

Coronary heart disease

CI:

Confidence interval

CVD:

Cardiovascular disease

ESC:

European Society of Cardiology

INOCA:

Ischemia with no obstructive coronary artery disease

IPAQ:

International Physical Activity Questionnaire

LDLc:

Low-Density Lipoprotein Cholesterol

LMDS:

Lebanese Mediterranean Diet Score

MET:

Metabolic equivalent

MI:

Myocardial infarction

MINOCA:

Myocardial infarction with no obstructive coronary artery disease

non-HDLc:

Non-High-Density Lipoprotein Cholesterol

ns:

Not significant

OR:

Odds ratio

PA:

Physical activity

RF:

Risk factor

SPSS:

Statistical Package for the Social Sciences

WHO:

World health organization

References

  1. Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, et al. Heart disease and stroke statistics-2022 update: a report from the American heart association. Circulation. 2022;145:e153–639.

    Article  PubMed  Google Scholar 

  2. Winzer EB, Woitek F, Linke A. Physical activity in the prevention and treatment of coronary artery disease. J Am Heart Assoc. 2018;7:e007725.

    Article  PubMed  PubMed Central  Google Scholar 

  3. World Health Organization. Global Strategy on Diet. Physical Activity and Health: World Health Organization; 2020.

    Google Scholar 

  4. Li J, Siegrist J. Physical activity and risk of cardiovascular disease—a meta-analysis of prospective cohort studies. Int J Environ Res Public Health. 2012;9:391–407.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Koolhaas CM, Dhana K, Golubic R, Schoufour JD, Hofman A, van Rooij FJA, et al. Physical activity types and coronary heart disease risk in middle-aged and elderly persons: the rotterdam study. Am J Epidemiol. 2016;183:729–38.

    Article  PubMed  Google Scholar 

  6. Al-Zoughool M, Al-Ahmari H, Khan A. Patterns of physical activity and the risk of coronary heart disease: a pilot study. Int J Environ Res Public Health. 2018;15:E778.

    Article  Google Scholar 

  7. World Health Organization. Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000- 2016. Geneva, Switzerland: World Health Organization. WHO. 2018. http://www.who.int/healthinfo/global_burden_disease/estimates/en/. Accessed 6 Jun 2020.

  8. Alsheikh-Ali AA, Omar MI, Raal FJ, Rashed W, Hamoui O, Kane A, et al. Cardiovascular risk factor burden in Africa and the Middle East: the Africa Middle East Cardiovascular Epidemiological (ACE) study. PLoS ONE. 2014;9:e102830.

    Article  ADS  PubMed  PubMed Central  Google Scholar 

  9. Isma’eel HA, Almedawar MM, Breidy J, Nasrallah M, Nakhoul N, Mouneimne Y, et al. Worsening of the cardiovascular profile in a developing country. Glob Heart. 2018;13:275–83.

    Article  PubMed  Google Scholar 

  10. Kohl HW, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G, et al. The pandemic of physical inactivity: global action for public health. Lancet Lond Engl. 2012;380:294–305.

    Article  Google Scholar 

  11. Bays HE, Taub PR, Epstein E, Michos ED, Ferraro RA, Bailey AL, et al. Ten things to know about ten cardiovascular disease risk factors. Am J Prev Cardiol. 2021;5:100149.

    Article  PubMed  PubMed Central  Google Scholar 

  12. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, Switzerland: World Health Organization; 2011.

    Google Scholar 

  13. Lee I-M, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women: is “no pain, no gain” passé? JAMA. 2001;285:1447.

    Article  CAS  PubMed  Google Scholar 

  14. Chomistek AK, Cook NR, Rimm EB, Ridker PM, Buring JE, Lee I ‐Min. Physical Activity and Incident Cardiovascular Disease in Women: Is the Relation Modified by Level of Global Cardiovascular Risk? J Am Heart Assoc. 2018;7.

  15. Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med. 2002;347:716–25.

    Article  PubMed  Google Scholar 

  16. Guthold R, Ono T, Strong KL, Chatterji S, Morabia A. Worldwide variability in physical inactivity. Am J Prev Med. 2008;34:486–94.

    Article  PubMed  Google Scholar 

  17. Li W, Procter-Gray E, Churchill L, Crouter SE, Kane K, Tian J, et al. Gender and age differences in levels, types and locations of physical activity among older adults living in car-dependent neighborhoods. J Frailty Aging. 2017;6:129–35.

    CAS  PubMed  PubMed Central  Google Scholar 

  18. Bellettiere J, LaMonte MJ, Evenson KR, Rillamas-Sun E, Kerr J, Lee I-M, et al. Sedentary behavior and cardiovascular disease in older women: the Objective Physical Activity and Cardiovascular Health (OPACH) Study. Circulation. 2019;139:1036–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Stamatakis E, Gale J, Bauman A, Ekelund U, Hamer M, Ding D. Sitting time, physical activity, and risk of mortality in adults. J Am Coll Cardiol. 2019;73:2062–72.

    Article  PubMed  Google Scholar 

  20. Mehilli J, Presbitero P. Coronary artery disease and acute coronary syndrome in women. Heart Br Card Soc. 2020;106:487–92.

    Google Scholar 

  21. Pacheco Claudio C, Quesada O, Pepine CJ, Noel BaireyMerz C. Why names matter for women: MINOCA/INOCA (myocardial infarction/ischemia and no obstructive coronary artery disease). Clin Cardiol. 2018;41:185–93.

    Article  PubMed  PubMed Central  Google Scholar 

  22. World Health Organization. NCD Country Profiles. Geneva: Switzerland; 2011.

    Google Scholar 

  23. Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study 2019. 2019. http://ghdx.healthdata.org/gbd-results-tool. Accessed 13 Mar 2021.

  24. Ghaddar F, Zeidan RK, Salameh P, Tatari S, Achkouty G, Maupas-Schwalm F. Risk factors for coronary heart disease among lebanese women: a case-control study. Vasc Health Risk Manag. 2022;18:297–311.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Zeidan RK, Farah R, Chahine MN, Asmar R, Hosseini H, Salameh P, et al. Prevalence and correlates of coronary heart disease: first population-based study in Lebanon. Vasc Health Risk Manag. 2016;12:75–84.

    Article  PubMed  PubMed Central  Google Scholar 

  26. McGorrian C, Yusuf S, Islam S, Jung H, Rangarajan S, Avezum A, et al. Estimating modifiable coronary heart disease risk in multiple regions of the world: the INTERHEART modifiable risk score. Eur Heart J. 2011;32:581–9.

    Article  PubMed  Google Scholar 

  27. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41:111–88.

    Article  PubMed  Google Scholar 

  28. American Diabetes Association. Standards of medical care in diabetes—2020 abridged for primary care providers. Clin Diabetes. 2020;38:10–38.

    Article  PubMed Central  Google Scholar 

  29. Piano MR, Thur LA, Hwang C-L, Phillips SA. Effects of alcohol on the cardiovascular system in women. Alcohol Res Curr Rev. 2020;40:12.

    Article  Google Scholar 

  30. Issa C, Jomaa L, Salamé J, Waked M, Barbour B, Zeidan N, et al. Females are more adherent to Lebanese mediterranean diet than males among university students. Asian Pac J Health Sci. 2014;1:345–53.

    Article  Google Scholar 

  31. Barbour B, Saadeh N, Salameh PR. Psychological distress in Lebanese young adults: constructing the screening tool ‘BDS-22.’ Int J Cult Ment Health. 2012;5:94–108.

    Article  Google Scholar 

  32. Helou K, El Helou N, Mahfouz M, Mahfouz Y, Salameh P, Harmouche-Karaki M. Validity and reliability of an adapted arabic version of the long international physical activity questionnaire. BMC Public Health. 2018;18:49.

    Article  Google Scholar 

  33. Marshall AL, Miller YD, Burton NW, Brown WJ. Measuring total and domain-specific sitting: a study of reliability and validity. Med Sci Sports Exerc. 2010;42:1094–102.

    Article  PubMed  Google Scholar 

  34. Kopp W. How Western diet and lifestyle drive the pandemic of obesity and civilization diseases. Diabetes Metab Syndr Obes Targets Ther. 2019;12:2221–36.

    Article  CAS  Google Scholar 

  35. Kahan D. Adult physical inactivity prevalence in the Muslim world: analysis of 38 countries. Prev Med Rep. 2015;2:71–5.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Kubesch NJ, ThermingJørgensen J, Hoffmann B, Loft S, Nieuwenhuijsen MJ, Raaschou-Nielsen O, et al. Effects of leisure-time and transport-related physical activities on the risk of incident and recurrent myocardial infarction and interaction with traffic-related air pollution: a cohort study. J Am Heart Assoc. 2018;7:e009554.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Raza W, Krachler B, Forsberg B, Sommar JN. Health benefits of leisure time and commuting physical activity: a meta-analysis of effects on morbidity. J Transp Health. 2020;18:100873.

    Article  Google Scholar 

  38. Biernat E, Piątkowska M. Leisure time physical activity among employed and unemployed women in Poland. Hong Kong J Occup Ther. 2017;29:47–54.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Folsom AR, Arnett DK, Hutchinson RG, Liao F, Clegg LX, Cooper LS. Physical activity and incidence of coronary heart disease in middle-aged women and men. Med Sci Sports Exerc. 1997;29:901–9.

    Article  CAS  PubMed  Google Scholar 

  40. Allesøe K, Holtermann A, Aadahl M, Thomsen JF, Hundrup YA, Søgaard K. High occupational physical activity and risk of ischaemic heart disease in women: the interplay with physical activity during leisure time. Eur J Prev Cardiol. 2015;22:1601–8.

    Article  PubMed  Google Scholar 

  41. Krause N, Brand RJ, Kaplan GA, Kauhanen J, Malla S, Tuomainen T-P, et al. Occupational physical activity, energy expenditure and 11-year progression of carotid atherosclerosis. Scand J Work Environ Health. 2007;33:405–24.

    Article  PubMed  Google Scholar 

  42. Bjørk Petersen C, Bauman A, Grønbæk M, Wulff Helge J, Thygesen LC, Tolstrup JS. Total sitting time and risk of myocardial infarction, coronary heart disease and all-cause mortality in a prospective cohort of Danish adults. Int J Behav Nutr Phys Act. 2014;11:13.

    Article  PubMed  Google Scholar 

  43. Owen N, Healy GN, Matthews CE, Dunstan DW. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38:105–13.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Dong L, Block G, Mandel S. Activities contributing to total energy expenditure in the United States: results from the NHAPS Study. Int J Behav Nutr Phys Act. 2004;1:4.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Park S, Lee J, Kang DY, Rhee CW, Park B-J. Indoor physical activity reduces all-cause and cardiovascular disease mortality among elderly women. J Prev Med Public Health Yebang Uihakhoe Chi. 2012;45:21–8.

    Article  PubMed  Google Scholar 

  46. de Lorgeril M, Salen P. Helping women to good health: breast cancer, omega-3/omega-6 lipids, and related lifestyle factors. BMC Med. 2014;12:54.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Stamatakis E, Hamer M, Lawlor DA. Physical activity, mortality, and cardiovascular disease: is domestic physical activity beneficial?: the Scottish health survey–1995, 1998, and 2003. Am J Epidemiol. 2009;169:1191–200.

    Article  PubMed  Google Scholar 

  48. Brownson RC, Eyler AA, King AC, Brown DR, Shyu YL, Sallis JF. Patterns and correlates of physical activity among US women 40 years and older. Am J Public Health. 2000;90:264–70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42:3227–337.

    Article  PubMed  Google Scholar 

  50. Stefanick ML, King AC, Mackey S, Tinker LF, Hlatky MA, LaMonte MJ, et al. Women’s health initiative strong and healthy pragmatic physical activity intervention trial for cardiovascular disease prevention: design and baseline characteristics. J Gerontol A Biol Sci Med Sci. 2021;76:725–34.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Adams SA, Matthews CE, Ebbeling CB, Moore CG, Cunningham JE, Fulton J, et al. The effect of social desirability and social approval on self-reports of physical activity. Am J Epidemiol. 2005;161:389–98.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank all our participants who shared with us their personal and intimate information. In addition, to all hospital administrations that agreed to participate in the study. Grateful thanks and recognition to the Military hospital team, especially Colonel Elie Fikani for their cooperation and facilitation of administrative issues.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Faculty of Public Health II, Lebanese University, Fanar, Lebanon

    Fatima Ghaddar

  2. Research Institute for Medical and Health Sciences, University of Sharjah, Sharjah, UAE

    Rouba K Zeidan

  3. INSPECT-LB, National Institute of Public Health, Clinical Epidemiology and Toxicology, Beirut, Lebanon

    Rouba K Zeidan & Pascale Salameh

  4. CERIPH, Center for Research in Public Health, Faculty of Public Health, Lebanese University, Mount-Lebanon, Lebanon

    Rouba K Zeidan

  5. Department of Research, Faculty of Pharmacy, Lebanese University, Hadath, Lebanon

    Pascale Salameh

  6. Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus

    Pascale Salameh

  7. School of Medicine, Lebanese American University, Byblos, Lebanon

    Pascale Salameh

  8. Faculty of Medicine, CHU Toulouse Rangueil, Toulouse, France

    Françoise Maupas-Schwalm

Authors
  1. Fatima Ghaddar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rouba K Zeidan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pascale Salameh
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Françoise Maupas-Schwalm
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

F.G. contributed to study design, data collection, data entry, statistical analysis and interpretation, manuscript drafting, and write-up of the paper. F.G. has full access to all the data in the study and takes responsibility for the integrity and accuracy of the data analysis. R.K.Z. contributed toward study conception, questionnaire design and article revision. P.S. contributed toward the study design and population, conception, analysis planning, sample size calculation, project supervision and article correction. F.M.S. contributed to the conception of the hypothesis, the study design and population, interpretation, working strategy, project supervision and critical review of the article. All authors have read and approved the final version of the manuscript.

Corresponding author

Correspondence to Fatima Ghaddar.

Ethics declarations

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Institutional Review Board (IRB) ethical committee of each participating hospital (Makassed General hospital [MGH.20.12.2018], Military Hospital [CMH.15.01.2019], Sacred Heart Hospital [HSC.15.12.2018], Lebanese Geitaoui Hospital [LHG-UMC.IRB-027], Rafik Hariri University Hospital [RHUH.26.12.2018], and Mount-Lebanon Hospital [MLH-UMC.18.12.2018]), in accordance with Lebanon’s ethical legislation, and the Declaration of Helsinki. The verbal informed consent process was confirmed by the IRB and obtained from all participants before the interview. Patients were informed that their response will be kept confidential.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ghaddar, F., Zeidan, R.K., Salameh, P. et al. Physical activity and odds of coronary heart disease among Lebanese women. BMC Public Health 24, 516 (2024). https://doi.org/10.1186/s12889-024-18042-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-024-18042-7

Keywords

BMC Public Health

ISSN: 1471-2458

Contact us