Risk factors for chronic venous disease:
The San Diego Population Study
Michael H. Criqui, MD, MPH,a,b Julie O. Denenberg, MA,a John Bergan, MD,c
Robert D. Langer, MD, MPH,e and Arnost Fronek, MD, PhD,c,d San Diego, Calif; and Danville, Pa
Background: The etiology of chronic venous disease in the lower limbs is unclear, and very limited data are available on
potential risk factors from representative population studies.
Methods: Participants in the San Diego Population Study, a free-living adult population randomly selected from age, sex,
and ethnic strata, were systematically assessed for risk factors for venous disease. Categorization of normal, moderate, and
severe disease was determined hierarchically through clinical examination and ultrasonography imaging by trained
vascular technologists, who also performed anthropometric measures. An interviewer administered a questionnaire and
an examination assessed potential risk factors for venous disease suggested by previous reports.
Results: In multivariable models, moderate venous disease was independently related to age, a family history of venous
disease, previous hernia surgery, and normotension in both sexes. In men, current walking, the absence of cardiovascular
disease, and not moving after sitting were also predictive. Additional predictors in women were weight, number of births,
oophorectomy, flat feet, and not sitting. For severe disease, age, family history of venous disease, waist circumference, and
flat feet were predictive in both sexes. In men, occupation as a laborer, cigarette smoking, and normotension were also
independently associated with severe venous disease. Additional significant and independent predictors in women were
hours standing, history of leg injury, number of births, and cardiovascular disease, but African American ethnicity was
protective. Multiple other postulated risk factors for venous disease were not significant in multivariable analysis in this
population.
Conclusions: Although some risk factors for venous disease such as age, family history of venous disease, and findings
suggestive of ligamentous laxity (hernia surgery, flat feet) are immutable, others can be modified, such as weight, physical
activity, and cigarette smoking. Overall, these data provide modest support for the potential of behavioral risk-factor
modification to prevent chronic venous disease. ( J Vasc Surg 2007;46:331-7.)
Abnormalities of the veins in the lower limbs are responsible for significant and widespread morbidity. The
prevalence of venous disease increases with age,1 and an
aging world population is likely to result in an increase in
venous disease. The etiology of chronic venous disease is
poorly understood, however, and some results are contradictory. A recent review1 showed that there are many
hypotheses pertaining to the development of varicose veins,
chronic venous insufficiency (CVI), and venous ulcers,
which has been the most frequently explored in previous
studies, but it is less common than other manifestations.
In the San Diego Population Study (SDPS), we systematically examined the relationship of a wide variety of potential
risk factors to both visible and functional venous disease. The
risk factors considered included family history,2-9 connective
tissue laxity,10-15 previous lower limb trauma,16,17 factors
related to cardiovascular disease (CVD),18,19 positional factors,20-28 physical measures,29-36 smoking,6 constrictive
From the Departments of Family and Preventive Medicine,a Medicine,b
Surgery,c Bio-Engineering,d University of California, San Diego, CA, and
Geisinger Health System,e Danville, PA.
Competition of interest: none.
This research was supported by National Institutes of Health-National
Heart, Lung, and Blood Institute grant 53487 and National Institutes of
Health General Clinical Research Center Program grant MO1 RR0827.
Correspondence: Michael H. Criqui, MD, MPH, UCSD, Family and Preventive Medicine, 9500 Gilman Dr, MC 0607, La Jolla, CA 92093
(e-mail: mcriqui@ucsd.edu).
0741-5214/$32.00
Copyright © 2007 by The Society for Vascular Surgery.
doi:10.1016/j.jvs.2007.03.052
clothing,37-41 a period of immobility,42 physical activity,6,19
constipation,43-45 fiber intake,46,47 and hormonal factors.48-51 This is a report of our findings.
MATERIALS AND METHODS
Population. The population for this study was randomly selected from current and retired employees of the
University of California, San Diego (UCSD). Random
selection was made within strata defined by age, sex, and
ethnicity. The categories of 40 to 49 years, 50 to 59 years,
60 to 69 years, and 70 to 79 years defined the age strata.
Women were over-selected to allow additional power for
certain female-specific hypotheses. Ethnic minorities—Hispanics, African Americans, and Asians—were over-selected
to allow statistical power for contrasts by ethnicity. The
spouse or significant other of each randomly selected participant was also invited to participate in the study. Some
volunteers (n ⫽ 199) who had heard about the study and
who asked to participate were enrolled. By selecting individuals from all levels of education and occupation, and
both working and retired, we were able to study a broadbased population sample.
For all study procedures, participants provided signed
informed consent after a detailed introduction to the study.
The study was approved by the Committee on Investigations Involving Human Subjects of UCSD.
Registered vascular technologists were trained and
monitored for each component of the study visit. Particular
attention was given to close adherence to the study proto331
JOURNAL OF VASCULAR SURGERY
August 2007
332 Criqui et al
col, which specifically defined the criteria for each of the
venous conditions. Details of the protocol have been published.52
Disease classification. In previous reports from the
SDPS, we separately characterized each leg of each participant by four categories of visible disease: normal, telangiectasis or spider veins, varicose veins, or trophic changes;
and by three categories determined by duplex ultrasound
evaluation: normal, superficial functional disease, or deep
functional disease.52 Because of the large number of risk
factors evaluated, for simplicity, each leg for this report was
classified in three overall, mutually exclusive, hierarchical
categories: normal, moderate, or severe disease, as described:
Normal. Subjects without varicose veins, without trophic changes (lipodermatosclerosis, hyperpigmentation,
healed ulcer, or active ulcer upon visual inspection) and
without insufficiency or obstruction of either the deep or
superficial systems on inspection with duplex ultrasound
were classified as “normal.” This corresponds with C0 or
C1 with Pn in the revised CEAP classification.53
Moderate venous disease. Subjects with varicose veins
or reticular varices in the absence of trophic changes upon
visual inspection, or with either insufficiency or obstruction
of the superficial system or the perforating veins but not in
the deep system by duplex ultrasound imaging, were classified as having moderate disease. Limbs with a history of
vein stripping in the absence of severe disease were classified
as moderate. This corresponds with C2 or As or Ap in the
revised CEAP classification.53
Severe venous disease. Subjects with trophic changes
upon visual inspection or insufficiency or obstruction in the
deep system by duplex ultrasound imaging were classified
as having severe disease for this report. This corresponds
with C4 or C5 or C6 or Ad in the revised CEAP
classification.53
Risk factors. At the study visit, trained interviewers
followed a standardized protocol to obtain information on
demographics, lifestyle, and personal and family medical
history. The vascular technologists assessed anthropometric measures.
Ethnicity and occupation. Subjects self-defined their
race/ethnicity as: “White, not Hispanic,” “Hispanic/
Chicano,” “African American,” “Asian/Pacific Islander,”
“Native American,” or “Other.” The subject’s current
occupation (or last occupation, if retired) was classified by
the interviewer as “professional,” “technical/administrative/managerial,” “clerical/skilled,” “semi-skilled,” or
“laborer.”
Personal habits. Subjects estimated hours spent lying
down, sitting, walking, and standing, currently and as adults.
Subjects answered whether when sitting for long periods they
regularly got up to move around currently and as adults.
History of wearing constrictive clothing, including girdles,
corsets, abdominal braces, and exercise attire was assessed.
Subjects rated their level of physical activity relative to persons
their own age. Subjects estimated how often they engaged in
vigorous activity (with increased heart rate) for at least 20
minutes weekly. Smoking history, including current and average daily cigarette intake and years smoked was assessed.
Standardized self-administered dietary assessment forms were
analyzed by the Fred Hutchinson Cancer Research Center,
Seattle, Washington.54
Health history. Subjects’ cardiovascular health history,
history of high blood pressure and diabetes were ascertained. Questions about immobility and bowel activity
were asked. Side-specific determination was made of any
serious lower limb injuries. Subjects’ history of hernia surgery, diverticulosis, diverticulitis, and non-lower limb vein
abnormalities was assessed. Women were asked about their
reproductive history. Subjects self-reported whether they
had hypermobile joints and flat feet.
Family history. Family history (all first-degree relatives) of telangiectasis, varicose veins, blood clots in lower
limb veins, phlebitis, venous ulcer, pulmonary embolism,
or other venous problems was assessed.
Anthropometrics. The subjects’ height, weight, heart
rate, waist, and hip circumferences were measured. Blood
pressures were measured in the right arm after the subject
had been sitting quietly for 5 minutes. The standing footarch height was visually ranked as flat, small, or
normal/high.
Quality control. In a standardized fashion, interviewers were trained to administer the questionnaire protocol,
and the vascular technologists were trained in the physical
examination and duplex ultrasound imaging protocol, with
periodic assessment for quality control. The reliability data
have been published.55 Range checks were conducted of all
numeric variables entered in the Access database (Microsoft, Redmond, Wash). A 2% random sample was further checked against the chart, and outliers for each individual variable were also systematically checked against the
chart.
Statistical analysis. All analyses were conducted using
the SAS 8.1 software (SAS Institute, Cary, NC). Ageadjusted univariate analyses and all multivariable analyses
used logistic regression. Multivariable analyses used entry
criteria of P ⬍ .3 and removal criteria of P ⬎ .1 for forward
step-wise logistic regression to develop the final models.
Age and indicator variables for ethnicity were included in all
models.
RESULTS
The study population consisted of 854 men and 1580
women with mean (⫾ standard deviation) ages of 60.1 ⫾
11.4 years and 58.8 ⫾ 11.4 years, respectively. The ethnic
distribution was approximately 60% non-Hispanic White
(NHW), 15% Hispanic, 13% African American, and 12%
Asian. We have previously published the relationship of
venous disease by sex, age, and ethnicity in the study
population.52 Table I summarizes the sex-specific percentage distributions of moderate and severe disease in the
SDPS by age and ethnicity. Both moderate and severe
venous disease increased with age. Women had nearly twice
the rate of moderate disease as men did, but men had
higher rates of severe disease. The disease distribution was
JOURNAL OF VASCULAR SURGERY
Volume 46, Number 2
Criqui et al 333
Table I. Demographic distribution of venous disease in men and women by age and ethnicity*
Men (%)
Variable
Age
⬍50
50-59
60-69
70⫹
Ethnicity
NHW
Hispanic
Afr-Am
Asian
Women (%)
No.
NL
MOD
SEV
No.
NL
MOD
SEV
185
240
198
201
77.3
75.4
66.7
59.2
10.8
11.7
14.1
15.4
11.9
12.9
19.2
25.4
417
412
395
356
72.7
67.5
56.7
52.3
19.2
22.6
28.9
30.6
8.2
10.0
14.4
17.1
560
84
78
102
67.3
70.2
79.5
77.5
14.1
17.9
7.7
6.9
18.6
11.9
12.8
17.7
876
269
245
190
60.4
60.0
67.4
71.1
25.7
30.5
22.9
17.4
13.9
9.3
9.8
11.6
NL, Normal, MOD, moderate; SEV, severe; NHW, Non-Hispanic White; Afr-Am, African-American.
*Some percentages do not total to 100 because of rounding.
Table II. Distribution of risk factors in men and women by moderate and severe venous disease
Men (n ⫽ 824)
Weight, kg
Waist, cm
Current cigarettes/d
DBP, mm/Hg
Current walking, hrs
Current standing, hrs
Adult sitting, hrs
History of CVD, %
Hypertension, %
Hernia surgery, %
Flat feet, %
Flat arch, %
Small arch, %
Family history venous disease, %
Leg injury, %
Current movement after sitting, %
Laborer, %
Births (n)
Oophorectomy, %
Women (n ⫽ 1570)
NL
MOD
SEV
NL
MOD
SEV
82.1
96.1
0.7
79.0
4.6
3.4
7.6
12.0
36.4
15.7
13.0
10.2
27.9
42.6
26.3
96.0
2.3
NA
NA
82.8
96.1
0.9
77.7
5.4
3.1
7.1
3.7
28.0
29.9
15.9
9.5
26.7
63.6
28.0
92.5
2.8
NA
NA
84.8
99.5
1.5
76.2
4.9
3.2
7.3
22.5
42.3
21.8
18.3
12.7
30.6
59.2
28.9
95.8
5.6
NA
NA
68.6
84.8
0.6
75.9
4.9
3.3
7.4
5.5
32.5
3.2
12.0
5.6
23.0
57.5
19.9
96.0
1.3
2.0
16.7
70.6
86.3
0.4
76.5
5.4
3.5
6.6
6.1
30.9
7.3
15.9
7.0
24.4
74.5
20.7
96.7
1.5
2.6
24.0
72.5
89.4
0.6
75.3
5.0
3.7
6.7
12.4
44.0
6.7
15.1
12.7
29.1
69.4
28.0
97.4
1.6
2.5
21.2
NL, Normal; MOD, moderate; SEV, severe; CVD, cardiovascular disease; DBP, blood pressure; NA, not applicable.
significantly different for men and women (␹2 P ⬍ .0001).
Hispanic subjects had the highest rates of moderate, and
NHW subjects had the highest rates of severe disease.
Table II summarizes the distribution of risk factors by
venous disease category—normal, moderate, or severe—and
by sex. These variables were selected from a long list of
potential risk factors because each showed univariate relationships with moderate or severe venous disease. Thus, they were
included in the multivariable logistic regression models discussed in the next section. Variables that showed no univariate
associations included multiple dietary factors such as fiber
intake, bowel habits, and gastrointestinal problems; regular
physical activity, and constrictive clothing.
MULTIVARIABLE MODELS
Moderate disease. The four variables of age, family
history of venous disease, previous hernia surgery, and
hypertension were highly significant for moderate disease in
men and women in multivariable analysis (Table III). The
respective odds ratios (OR) were 1.59 in men and 1.43 in
women for age (per decade); 2.87 and 2.34 for family
history, 1.85 and 1.81 for hernia surgery; but hypertension
showed an inverse relationship, with ORs of 0.58 and 0.64,
respectively. All the confidence intervals for these associations excluded the null hypothesis. Although moderate
disease, compared with NHW, was greater in Hispanic
subjects and less in African American and Asian subjects,
none of these associations reached statistical significance.
Additional significant predictors in men, in order of
statistical significance by OR were current walking (per
hour), 1.14; history of CVD, 0.22; and a protective association for current moving around after sitting for long
periods, 0.31. In women, additional predictors in order of
statistical significance by OR were adult life sitting (per
JOURNAL OF VASCULAR SURGERY
August 2007
334 Criqui et al
Table III. Risk factors for moderate venous disease (vs normal) in men and women*
Men
Variable
Age (10 years)
African-American
Asian
Hispanic
Venous disease, family history
Hernia surgery
Hypertension
CVD history
Current
Walking (per hr)
Move after sitting
Adult sitting (per hour)
Weight (10 kg)
Births (n)
Waist circumference (10 cm)
Oophorectomy
Flat feet
Women
Point estimate
95% CI
Point estimate
95% CI
1.59
0.64
0.55
1.48
2.87
1.85
0.58
0.22
1.26, 2.00
0.25, 1.60
0.23, 1.29
0.74, 2.94
1.81, 4.55
1.09, 3.14
0.34, 0.98
0.08, 0.66
1.43
0.84
0.90
1.21
2.34
1.81
0.64
—
1.25, 1.64
0.57, 1.24
0.57, 1.42
0.85, 1.70
1.77, 3.10
1.04, 1.34
0.47, 0.87
—
1.14
0.31
—
—
NA
—
NA
—
1.05, 1.24
0.13, 0.79
—
—
NA
—
NA
—
—
—
0.92
1.32
1.14
0.83
1.37
1.39
—
—
0.87, 0.96
1.12, 1.56
1.05, 1.23
0.69, 1.00
1.00, 1.87
0.97, 2.00
CI, Confidence interval; CVD, cardiovascular disease; NA, not applicable.
*Multivariable entry into model 0.3, exit 0.1.
Table IV. Risk factors for severe venous disease (vs. normal) in men and women*
Men
Variable
Age (10 years)
African American
Asian
Hispanic
Venous disease, family history
Waist circumference (10 cm)
Laborer
DBP (10 mm/Hg)
Current cigarettes (20/day)
Flat feet
Flat arch (vs normal)
Current standing (per hr)
Small arch (vs normal)
Leg injury
Births (n)
CVD history
Women
Point estimate
95% CI
Point estimate
95% CI
1.41
0.63
1.50
0.63
2.13
1.37
3.24
0.80
2.24
1.63
—
—
—
—
NA
—
1.17, 1.70
0.30, 1.35
0.81, 2.75
0.28, 1.39
1.44, 3.16
1.15, 1.63
1.21, 8.67
0.67, 0.97
1.11, 4.54
0.97, 2.75
—
—
—
—
NA
—
1.43
0.44
0.99
0.71
1.92
1.24
—
—
—
—
3.28
1.14
1.84
1.67
1.14
2.02
1.21, 1.68
0.26, 0.77
0.57, 1.74
0.42, 1.19
1.33, 2.77
1.11, 1.39
—
—
—
—
1.83, 5.89
1.05, 1.24
1.25, 2.71
1.14, 2.44
1.03, 1.27
1.14, 3.56
CI, Confidence interval; DBP, diastolic blood pressure; CVD, cardiovascular disease; NA, not applicable.
*Multivariable entry into model 0.3, exit 0.1.
hour), 0.92; weight (per 10 kg), 1.32; number of births
(per birth), 1.14; waist circumference (per 10 cm), 0.83;
previous oophorectomy, 1.37; and flat feet, 1.39.
Severe venous disease. The three variables of age,
family history of venous disease, and waist circumference
were highly significant for severe disease in both men and
women in multivariable analysis (Table IV). The ORs in
men and women, respectively, were 1.41 and 1.43 for age;
2.13 and 1.92 for family history, and 1.37 and 1.24 for
waist circumference. The only significant association for
ethnicity was a reduced OR of severe disease in African
American women (0.44). The data for African American
men were also suggestive (0.63), but the confidence interval included one.
Additional significant predictors in men, in order of
statistical significance by OR, were occupation as a laborer,
3.24; diastolic blood pressure (per 10 mm/Hg), 0.80;
current cigarettes per day (per 20 cigarettes), 2.24; and flat
feet, 1.63. Additional predictors in women, in order of
statistical significance by OR, were flat (3.28) or small
(1.84) foot arch; current standing (per hour), 1.14; previous leg injury, 1.67; number of births (per birth), 1.14; and
history of CVD, 2.02.
DISCUSSION
Age, sex, and ethnicity were important risk factors for
venous disease in this study, as in most previous studies.1,52
Our results confirm that older age is a risk factor for venous
JOURNAL OF VASCULAR SURGERY
Volume 46, Number 2
disease. They also showed no significant ethnic differences
for moderate disease, but severe disease may be less common in African American women.
Family history was a risk factor for both moderate and
severe disease. Many studies have found an association with
family history and venous disease,2-7 although not all.8,9 As
other researchers have pointed out, biased recall could have
influenced this finding.9,56 Nevertheless, family history by
subject recall was a very strong risk factor for venous disease
in our study. In addition, Table II shows that subjects
without venous disease reported high rates of a family
history of venous disease.
Connective tissue laxity, as manifested by previous hernia surgery or findings of flat feet, was a consistent risk
factor for both moderate and severe disease. The association of increasing laxity in connective tissue with venous
disease corroborated previous research.10-13 It is possible
that previous hernia surgery may have been a marker for
previous hospitalization and immobility; however, immobility was not significantly associated with venous disease in
our data.
Lower limb injury was a risk factor in women for severe
disease. This finding corresponds with the results of Bermudez et al,16 who noted that insufficiency in the deep
veins was increased in limbs that had experienced trauma
compared with limbs that had not. A case-control study8
similarly found serious lower limb trauma to be a risk factor
for CVI; however, an earlier study17 found no difference in
CVI for injured vs uninjured limbs.
Factors related to CVD, specifically hypertension, previous CVD, and higher diastolic blood pressure, were associated with less moderate disease for men and women and
with less severe disease for men. Conversely, a history of
CVD was strongly associated with severe disease in women.
Although some studies have found a relationship between
atherosclerosis and venous disease,18,19 others have not.3
The reason for any protective effect of atherosclerosis on
moderate or severe venous disease is not readily apparent,
although relative arterial insufficiency, venous vasoconstriction, and microthrombosis could conceivably be involved.
Positional factors such as walking, standing, and sitting
showed variable associations with venous disease. In
women, increased time standing was positively associated
with more severe disease, and increased sitting time was
inversely associated with moderate disease. For men, increased daily walking was associated with moderate disease,
and men who worked as laborers were more likely to have
severe disease than those in occupations that typically require more desk time.
Regular movement when sitting for long periods was
related to lower rates of moderate disease in men. Fowkes et
al20 similarly found that sitting was associated with lower
rates of venous insufficiency for women but not for men.
They also found that walking was a risk factor for women
with venous insufficiency when age-adjusted, but less so
when multiply adjusted, and that walking was related to
lessened risk of venous insufficiency in men.20
Criqui et al 335
Our data indicate that standing was a strong risk factor
for severe venous disease in women. This is concordant
with a number of studies3,4,6,7,21-26 and contrasts with
others.9,20,27,28 Our finding that moving about if sitting
for long periods of time was related to lower rates of
moderate disease for men concurs with the hydrostatic
model of venous disease. That is, although sitting and lying
are generally more protective than walking or standing,
some pooling of blood is still possible during the former
activities. Moving about could activate the venous pump
and prevent such pooling.
Physical measures were risk factors for women with
both severe and moderate disease and for men with severe
disease. Weight and waist circumference are both measures
of adiposity. A number of studies have found an association
of obesity with venous disease. Sisto et al29 and Gourgou et
al6 found a relationship in both men and women with
varicose veins, Widmer et al21 and Abramson et al30 both
found an association for women, and Beaglehole et al36
found an association for men. Our finding of increased
waist circumference in both sexes with severe disease was
consistent with the Scott et al5 finding that obesity was
associated with CVI and by the Mota-Capitao et al31 finding that weight was an independent risk factor for CVI in
multivariable analysis.
In contrast, Coughlin et al8 and Fowkes et al20 both
found that obesity was not a factor in venous insufficiency
among women, and Fowkes et al extended this finding to
men as well. Other studies have also found no association
between obesity and venous disease.3,28,32-34 The Edinburgh group,20 however, also found that for men and
women combined, persons with more segments with reflux
had higher body mass indices than those with fewer or no
segments involved.
Hormonal factors in women, number of births, and
oophorectomy were related to moderate or severe venous disease, or both. Gourgou et al6 and Laurikka et al7
found an increasing varicose vein prevalence with increasing numbers of births. Coughlin et al8 found that
multiparity was associated with varicose veins in pregnant women, as did Sisto et al,28 Maffei et al,29 and Sohn
et al.48 Some studies have found that the changes occur
with only one pregnancy.3,4,21,30 In Guberan et al22 and
Lee et al,49 pregnancy was no longer a risk factor once
the data had been age-adjusted. In two studies, Sparey et
al50,51 evaluated women with and without varicose veins
at the beginning of pregnancy. Although neither group
presented with new varicose veins during pregnancy,
both had dilation of veins during pregnancy, and in
women without varicose veins, the diameter had not
returned to baseline size by 6 weeks postpartum.
Smoking was associated with increased rates of severe
disease for men. One study6 has shown that varicose veins
was associated with higher numbers of cigarettes smoked
per day, but to our knowledge, our study is the first to
report a sex-specific association of smoking limited to severe venous disease.
JOURNAL OF VASCULAR SURGERY
August 2007
336 Criqui et al
Constrictive clothing, immobility, exercise, constipation, and dietary fiber were not risk factors for moderate or
severe disease in multivariable models. Multiple questions
addressed each of these five categories of potential risk
factors, but none were statistically significant in multivariable analysis. Thus, despite biologic plausibility for such
factors and some earlier reports, we were unable to confirm
the importance of such factors in peripheral chronic venous
disease in this large population-based study.
Study limitations. Study limitations of these results
include the cross-sectional study design, where correlations
do not necessarily imply causation. In addition, some of the
risk factors reviewed were self-reported, and no formal
validation was done of the subjects’ responses. A specific
concern in this area was the strong and independent association of a family history of venous disease for both men
and women and for both moderate and severe disease,
which could reflect recall bias to some extent. However,
about half the participants with normal veins reported a
family history of venous disease, so such reporting was
common in those with and without venous disease.
CONCLUSION
This comprehensive cross-sectional study of venous
disease helps to clarify the contributions of a variety of risk
factors to moderate and severe venous disease. Our data
indicate that age, family history, and ligamentous laxity
were the strongest and most consistent risk factors for
venous disease. None of these conditions is amenable to
intervention, and thus, these findings have little implication
for disease prevention. Factors related to CVD were generally associated with lower rates of venous disease.
A number of behavioral and environmental factors did
show significant relationships, however. Among volitional
factors important findings were central adiposity, positional
factors such as hours spent standing or sitting, cigarette
smoking, and parity in women, and all but the latter variable are reasonably subject to intervention. In addition,
prevention of or intervention on obesity and cigarette
smoking would help prevent conditions such as CVD and
cancer. In women (but not men) we confirmed the importance of a previous lower limb injury for severe disease.
These data provide modest support for the potential of
behavioral risk-factor modification to prevent chronic venous disease. Incidence studies would provide greater understanding of the role of risk factors in the development
and progression of moderate and severe venous disease.
AUTHOR CONTRIBUTIONS
Conception and design: MC, JD, AF
Analysis and interpretation: MC, JD, JB, RL, AF
Data collection: MC, RL, AF
Writing the article: MC, JD
Critical revision of the article: MC, JD, JB, RL, AF
Final approval of the article: MC, JD, JB, RL, AF
Statistical analysis: MC, JD
Obtained funding: MC
Overall responsibility: MC
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Submitted Jan 23, 2007; accepted Mar 30, 2007.