HEALTH AND WELLNESS 1/2013
HEALTH AND WELLNESS
CHAPTER IV
1
Department of Normal Anatomy, Wroclaw Medical University
Katedra i Zakład Anatomii Prawidłowej
Uniwersytetu Medycznego we Wrocławiu
2
Department of Pathophysiology, Wroclaw Medical University
Katedra i Zakład Patofizjologii Uniwersytetu Medycznego we Wrocławiu
3
Centre of Men’s Health, Wroclaw
Centrum Zdrowia Mężczyzny Wrocław
4
Wroclaw University of Technology – Department of Foreign Languages
Studium Języków Obcych Politechniki Wrocławskiej
5
The School of Higher Vocational Education in Nysa
Wyższa Szkoła Muzyczna w Nysie
6
Department of Dental Anatomy, Wroclaw Medical University
Zakład Anatomii Stomatologicznej
Uniwersytetu Medycznego we Wrocławiu
ZYGMUNT A. DOMAGAŁA1, DARIUSZ KALKA2,3,
PAWEŁ DĄBROWSKI1, MAREK SYRYCKI1, MIROSŁAW TRZASKA1,
SŁAWOMIR WOŹNIAK1, RYSZARD KACAŁA1,
MICHAŁ PORWOLIK1, JOANNA GRUSIECKA-DOMAGAŁA4,
MAGDALENA PIŁOT5, WIESŁAW KURLEJ6, BOHDAN GWORYS1
A Pilot Study of Wellness of the Circulatory System
in First-Year Foreign Medical Students in Wroclaw
Dobrostan układu krążenia u studentów I roku English Division
we Wrocławiu – badanie pilotażowe
INTRODUCTION
The development of civilisation in the 19th century, and especially in the 20th
century, brought a complete change in the lifestyle of most Europeans. Once permanently undernourished, physically hard-working serfs to kings, they became independent citizens of democratic states. Changes in the political situation followed
from economic changes. Industry development and access to cheap sources of energy caused agriculture mechanization and a rapid demand for workforce in cities.
Progressing scientific and economic growth led to rapid social changes. Large
groups of citizens stopped working physically and plenty of sitting jobs appeared.
HEALTH AND WELLNESS 1/2013
Health and wellness
The development of public and private transport changed peoples’ habits to an even
greater extent. The 18th century Europeans used their own muscles to travel. Today
they move thanks to motor-driven machines. Also, in the 20th century medicine
development followed the industry development. Diarrhoea and puerperal fever,
fatal in the 19th century, stopped taking its death toll in the second half of the 20th
century. The development of antibacterial drugs practically eliminated the risk of
death due to infections. The appearance of first aid and emergency care changed the
fate of victims of accidents or those who fell ill suddenly. The emergence of vaccines eliminated many fatal diseases of infancy and childhood. The development of
chemistry allowed patients to survive surgery. As a result of all these changes, the
average life span of human beings has increased radically. Mortality and prevalence
rates have changed throughout Europe. The leading cause of death in Europe became diseases whose development is a result of many years of pathological processes. However, even today we do not know the direct underlying causes of these processes. As human beings we only see their consequences. In Poland, since mid-20th
century the leading cause of death is atherosclerosis. The most common consequence of atherosclerosis are cardiovascular diseases (CVDs).
It thus became important to determine the risk factors for cardiovascular diseases. The first multicenter clinical trial whose goal was to define major modifiable risk
factors for ischaemic heart disease was the Framingham Heart Study. The study was
commenced just after WWII and focused on the population of Framingham, Massachusetts, USA. The study continues up to today. The idea of the study was to assess,
over a long period of time, a large group of people in whom no symptoms of cardiovascular diseases had yet been observed. Almost the entire population of the town
(approximately 5200 people) participated in the first edition of the study. Since the
70s, children of the first group, along with their spouses, were included in the study,
and since the beginning of the 21st century grandchildren of the first subjects participate in the study.
The first years of research and of recording the cause of death in a selected population allowed to identify features that were called the risk factors for ischaemic
heart disease. Recognized risk factors for cardiovascular diseases include: age, sex,
hypertension, smoking, dyslipidaemia and diabetes [1].
Equally important studies conducted in other parts of the world include the Seven Countries Studies and the Whitehall Study. The multicentre Seven Countries
Studies showed that significant risk factors for myocardial infarction or death due to
cardiovascular causes include: age, smoking, lipid disorders and hypertension [2].
In the Whitehall and Whitehall II trial, researchers also showed that age, smoking, lipid disorders, hypertension and BMI are related to mortality and prevalence
due to cardiovascular causes [3].
The demonstrated major risk factors for cardiovascular diseases still do not fully
allow to predict the risk of cardiovascular events in individual patients. Therefore,
attempts are still being made to identify other risk factors, which together with the
major ones, would make it possible to precisely analyse the risk of cardiovascular
50
Zygmunt A. Domagała, Dariusz Kalka, Paweł Dąbrowski, Marek Syrycki,
Mirosław Trzaska, Sławomir Woźniak, Ryszard Kacała, Michał Porwolik,
Joanna Grusiecka-Domagała, Magdalena Piłot, Wiesław Kurlej, Bohdan Gworys
A Pilot Study of Wellness of the Circulatory System
in First-Year Foreign Medical Students in Wroclaw
disease in an individual patient. One such study is the INTERHEART study. Researchers from the INTERHEART work group attempted to assess risk factors for
cardiovascular diseases in as many countries as possible. They introduced the term
‘population attributable risks’ and proved that abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low consumption of fruits,
vegetables, high consumption of alcohol, and lack of regular physical activity account for most of the risk of myocardial infarction worldwide in both sexes and at
all ages in all regions [4].
The previously cited multicentre trials indicate a critical role of modifiable risk
factors for cardiovascular disease in preventing cardiovascular events and cerebral
infarctions. However, in order to be able to effectively impact large groups of potential future patients, national prevention programmes are needed. It also seems crucially important that medical professionals are not only well informed about these
factors, but also follow the recommendations resulting from the multicentre clinical
trials. Therefore, at Wroclaw Medical University a long-term programme assessing
students’ knowledge about modifiable risk factors for cardiovascular disease and
analysing intensity of leisure time physical activity (LTPA) was commenced.
Initial preliminary data obtained from medical students were published in 2012
[5,6]. The data indicate a surprisingly low level of knowledge among Polish students
and difficulties in following health-oriented recommendations. This work aims at a
preliminary assessment of these data among students of the English Division of
Wroclaw Medical University, i.e. among foreign medical students in Poland.
The study was meant as a pilot study assessing knowledge about risk factors for
cardiovascular diseases and the following of recommendations related to healthoriented lifestyle by young adult medical students of the English Division.
MATERIALS AND METHODS
The study was conducted between 2012 and 2013 in a group of 81 first-year
medical students of the English Division of Wroclaw Medical University (mean age
20.46±1.54 years). The test group consisted of 37 women (mean age 20.24±1.77
years) and 42 men (mean age 20.69±1.84 years). The students were natives of many
countries worldwide. Data were arranged according students country of birth . Five
groups were taken into account: Europe, Poland, Middle East, America and Other
(Fig. 1).
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50
40
Poland
Europe
30
Middle East
20
America
Other
10
0
Figure 1. Students country of birth (no. of cases)
The study questionnaire consisted of two parts. Part I – an original survey – contained 27 questions on three selected subjects. The first group of questions concerned basic information on education, origin and history of the participants. The
second group of questions concerned students knowledge about risk factors for cardiovascular diseases. In this part, students had to, among other things, define 5 major, in their opinion, risk factors for CVD. The third part of the questionnaire assessed whether students followed basic recommendations for a healthy lifestyle. The
first part of the questionnaire also included a simple task, to assess preliminarily
students physical capacity. The task was to assess own heart rate before and after 10
knee bends. Heart rate was assessed by measuring it in the common carotid artery in
the carotid trigone. Study participants were instructed how to measure heart rate
properly in this location. In the second part of the questionnaire, a physical activity
questionnaire based on the Framingham questionnaire was used to assess the students’ weekly intensity of leisure time physical activity (defined as planned, intended and regular forms of leisure time physical activity) as well as the students’ commuting activity either on foot or by bicycle, provided that it lasted once longer than
15 minutes. Respondents were assigned to one of three physical activity categories:
<1000, 1000-1999 and ≥2000 kcal/week. In accordance to the recommendations,
≥1000 and ≥ 2000 kcal/week were taken as the standard for minimal and optimal
leisure time physical activity (LTPA), respectively. The study was approved by the
local bioethics committee.
RESULTS
I – knowledge about risk factors
Students on average correctly defined 2.93±1.70 risk factors for cardiovascular
diseases (women named on average 3.40±1.49 cardiovascular risk factors and men
2.51±1.79). The difference between the sexes was statistically significant (p=0.018).
Medical education of the students’ parents was related to a statistically significantly
52
Zygmunt A. Domagała, Dariusz Kalka, Paweł Dąbrowski, Marek Syrycki,
Mirosław Trzaska, Sławomir Woźniak, Ryszard Kacała, Michał Porwolik,
Joanna Grusiecka-Domagała, Magdalena Piłot, Wiesław Kurlej, Bohdan Gworys
A Pilot Study of Wellness of the Circulatory System
in First-Year Foreign Medical Students in Wroclaw
greater number of correctly defined risk factors (3.45 vs 2.69, p=0.0443). Similarly,
personal average LTPA was compared with correctly defined risk factors and the
difference occurred to b statistically significant (3.31 vs 2.19, p=0.007). The number
of correct answers was not statistically significant to these having smoking parents
(p=0.47), intensity of own physical activity (p=0.43) and smoking by the study participants (p=0.53). The most frequently named risk factor for cardiovascular diseases
was poor diet high in saturated animal fats. Apart from that, the study participants
often indicated smoking, stress or lack of physical activity as behaviour favouring
cardiovascular diseases. Basic data are presented in Figure 2.
60
High fat diet
50
Lack of Physical Activity
Tobacco usage
40
Obesity
30
Stress
20
Genetic f.
10
0
Hypertension
Diabetes
High cholesterol
Figure 2. Most frequently cardiovascular risk factors named by ED students
Interestingly, 13 students considered the intake of any amount of ethyl alcohol as
a risk factor for atherosclerosis, and several students considered owning a cat as a
risk factor for CVD. Eighty-five percent of students declared the knowledge of lowfat diet, fifty-eight percent of the knowledge of dietary recommendations in low-salt
diet, and sixty-eight percent of the understanding of the principles of the Mediterranean diet.
II – following recommendations
In the analysed group of students, 11 (13.5%) smoked tobacco, 21 (26%) were
obese, 49 (60.5%) did not follow a low-fat diet, 59 (73%) did not follow a low-salt
diet, and 50 (62%) did not follow the Mediterranean diet. Lack of physical activity
was declared by 14 (18%) students, however 54 (67%) declared the need to increase
their physical activity. Mean intensity of leisure time physical activity in the analysed group was 1035 kcal/week (SD 2086.34), i.e. slightly above the established
standard of minimal intensity of leisure time physical activity. In the group of women, mean LTPA was 521.64+/-684 kcal/week, so it was below recommended standards. In the group of men, mean LTPA was 1477+/-2731 kcal/week. LTPA intensity
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Health and wellness
was relating to the medical education of parents (p=0.0427). LTPA intensity was
related to post-exercise heart rate. The correlation, expressed by Pearson’s coefficient was: r=-0.1227. Too low intensity of leisure time physical activity was presented by 75% of students (29 men and 32 women). Physical activity in the range
1000-1999 kcal/week was presented by 11% of students (4 women and 5 men) and
in the range over 2000 kcal/week by 14% of students (2 women and 9 men). The
highest confirmed LTPA in a week was presented by a male student (15876
kcal/week) and it was mainly due to athletic workouts in his free time.
Resting heart rate measured in the carotid trigon was 77.81+/-10.60 bpm in the
entire group of the tested students (78.24+/-9.76 in women and 77.07 +/-11.29 in
men(p=0.62)). Intensity of leisure time physical activity was negatively correlated
with resting heart rate measured in the common carotid artery. It is expressed by
Pearson’s correlation coefficient r=-0.26.
Post-exercise heart rate measured in the common carotid artery was on average
113.43 +/-17.74 bpm. In the women group, heart rate was 112.5+/-20.56 bpm an in
the men group it was 113.5+/-15.16 bpm. The difference was not statistically significant. No relation between post-exercise heart rate and LTPA was shown.
DISCUSSION
Ischeamic heart disease is today the leading cause of death of men and one of the
leading causes of death of women. It reduces life expectancy, accelerates the onset
of disability, and removes from the population fit and relatively healthy people, who
otherwise might live to a ripe old age. The world of science has focused on treatment of cardiovascular diseases. In recent years, many anticoagulants and new
chemical substances have been introduced for fighting atherosclerosis or hypertension. Works on the development of various techniques for invasive treatment of
ischaemic heart disease are carried our continuously. At the same time, cardiovascular disease treatment is very expensive and increases the costs of health care in developed countries. There is, however, an easier way to treat or even cure many people of cardiovascular diseases. It is primary prevention, i.e. preventing a disease
from appearing. Also very effective is secondary prevention, i.e. pharmacological
and non-pharmacological treatment of patients. Secondary prevention is both effective and relatively inexpensive. However, in order to promote non-pharmacological
ways of avoiding cardiovascular diseases and non-pharmacological treatment of
cardiac diseases it is necessary that physicians have a basic knowledge about risk
factors for cardiovascular diseases. It is also important that they set an example of
health-oriented behaviour for patients.
Literature data indicate that knowledge of first-year medical students is low. For
example, in the study by Reiner et al. [7], Croatian students considered obesity, high
cholesterol and hypertension as significant cardiovascular risk factors. They considered smoking, diabetes and stress as moderately important risk factors. Surprisingly,
they considered lack of physical activity, low HDL and genetic factors as factors
practically insignificant in the development of atherosclerosis. Slightly different data
was presented by researchers from Gulf Medical University [8]. They assessed first54
Zygmunt A. Domagała, Dariusz Kalka, Paweł Dąbrowski, Marek Syrycki,
Mirosław Trzaska, Sławomir Woźniak, Ryszard Kacała, Michał Porwolik,
Joanna Grusiecka-Domagała, Magdalena Piłot, Wiesław Kurlej, Bohdan Gworys
A Pilot Study of Wellness of the Circulatory System
in First-Year Foreign Medical Students in Wroclaw
year medical students’ knowledge about risk factors for hypertension (one of the
cardiovascular diseases, usually appearing first and preceding ischaemic heart disease or cerebral infarctions). United Arab Emirates students indicated psychosomatic stress (75%), obesity (73%), high cholesterol (73%), smoking (71%) and poor diet
(62%) as the cause of development of hypertension. Half of the students also indicated lack of physical activity (47%) and diabetes (50%). Foreign students studying
in Poland indicated similar risk factors for cardiovascular diseases: smoking
(60.5%), poor diet (68%) and psychosomatic stress (18%). Unlike the Croatian and
Gulf Medical University students, they also indicated the significant role of lack of
physical activity (60.4%). Interestingly, in the study by Shaikh RB et al. [8] the
majority of correct answers were provided by men, whereas the male students of
Wrocław Medical University answered statistically significant worse than the female students (p=0.018).
This – [one must say] not too extensive – knowledge about risk factors for cardiovascular diseases does not, however, translate into a health-oriented lifestyle. In the
tested group of students, smokers constituted 13.5%, which is similar to the data
given in the multicentre GHPSS study concerning medical students in most countries of the world. In this study, depending on the country the percentage of smokers
ranged between 4 and 5% and in some Arab countries even between 40 and 50% of
the population of students in Northern Europe or South America. This percentage is
thus not remarkably high, yet it is still too high from the perspective of promotion of
a healthy lifestyle by physicians [9].
Wroclaw Medical University students do not follow dietary recommendations.
Nelsow et al. indicates that when a young person moves from secondary school to
university, consumption of fast food grows radically. Fifty-two percent of young
adults declare that they eat fast food once daily. This is accompanied by a very low
consumption of fruit and vegetables. About 60% of young people eat daily less that
one meal containing fruit and vegetables. Interestingly, Nelsow et al. suggest that
available scientific data indicate an increase in the intake of candies and fizzy drinks
in a group of young adults compared to children.
In our study, about 60% of the students indicated that they did not follow dietary
recommendations. It is even more worrying considering that a lot of these people
understand and are aware of the importance of a healthy diet in preventing cardiovascular diseases. Interestingly, our observations conflict with the observations
made in a group of students in Malaysia. Most of these students (over 75%) regularly eat fruit and vegetables and consume meals together with their family or friends at
home. Malaysian students also avoid fast food. The authors suggest a significant
influence of culture and lack of sufficient funds as the reason for a healthier lifestyle
in this group of students [11].
As regards physical activity, lack of physical activity was declared by 18% of
Wroclaw Medical University students. It is similar to the Indian data presented by
Anand T. et al. [12]. In the group of Wroclaw Medical University students, too low
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leisure time physical activity was declared by 75% of students. This was similar to
the data of Anand T. et al. Indian students were in 20% of cases completely inactive
and in 47% of cases their activity was lower than the 1995 CDC recommendations
[13]. The 1995 recommendations indicate a necessary physical activity almost every
day, consisting in a 30-minute walk of moderate to high intensity. These recommendations are still less restrictive than the Polish ones, because in the case of a 30minute walk of a moderate intensity the number of kcal per week used during such
exercise does not exceed 1000 kcal. Resting heart rate in the group of the tested
students was 77.81 bpm. This value did not differ from the data reported in other
publications. For example, Milosevic [14] states that mean heart rate in nursing
students is approximately 82.8 bpm.
CONCLUSIONS
First-year medical students of the English Division demonstrate low knowledge
about risk factors for the most common disease of the 19th and 20th century. The
students’ level of knowledge translates only in average into following recommendations regarding health-oriented lifestyle. Most of them lead a sedentary lifestyle and
do not follow dietary recommendations. A family member with medical education
resulted in better scores in both parts of the questionnaire. Results of the preliminary
study are very interesting and therefore it is planned to extend the group of students
covered by the study.
LITERATURE
1. Oppenheimer GM Framingham Heart Study: the first 20 years. Prog Cardiovasc
Dis. 2010 53:55-61.
2. Menotti A, Keys A, Blackburn H. i wsp.. Comparison of multivariate predictive
power of major risk factors for coronary heart diseases in different countries: results from eight nations of the Seven Countries Study, 25-year follow-up. J Cardiovasc Risk. 1996 3:69-75.
3. Clarke R, Emberson J, Fletcher A. i wsp. Life expectancy in relation to cardiovascular risk factors: 38 year follow-up of 19,000 men in the Whitehall study.
BMJ. 2009 16;339:b3513.
4. Yusuf S, Hawken S, Ounpuu S i wsp., INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction
in 52 countries (the INTERHEART study): case-control study. Lancet. 2004
364(9438):937-52.
5. Kałka D., Domagała Z. A., Rusiecki L. i wsp.: Knowledge of risk factors for
cardiovascular diseases in development of healthy lifestyle habits among thirdyear students at Wroclaw Medical University. Eur.J.Prev.Cardiol. 2012 Vol.19
suppl.1; s.S52.
56
Zygmunt A. Domagała, Dariusz Kalka, Paweł Dąbrowski, Marek Syrycki,
Mirosław Trzaska, Sławomir Woźniak, Ryszard Kacała, Michał Porwolik,
Joanna Grusiecka-Domagała, Magdalena Piłot, Wiesław Kurlej, Bohdan Gworys
A Pilot Study of Wellness of the Circulatory System
in First-Year Foreign Medical Students in Wroclaw
6. Kałka D., Domagała Z. A., Rusiecki L. i wsp.: Influence of parents education on
knowledge of risk factors for atherosclerosis in population of third year medical
students. Eur.J.Prev.Cardiol. 2012 Vol.19 suppl.1; s.S108.
7. Reiner Ž, Sonicki Z, Tedeschi-Reiner E. The perception and knowledge of cardiovascular risk factors among medical students. Croat Med J. 2012 53:278-84.
8. Shaikh RB, Mathew E, Sreedharan J i wsp.. Knowledge regarding risk factors of
hypertension among entry year students of a medical university. J Family Community Med. 2011 18:124-9.
9. Charles W. Warren, Dhirendra N. Sinha, Juliette Lee,Veronica Lea, Nathan R.
Jones Tobacco Use, Exposure to Secondhand Smoke, and Training on Cessation
Counseling Among Nursing Students: Cross-Country Data from the Global
Health Professions Student Survey (GHPSS), 2005–2009. Int. J. Environ. Res.
Public Health 2009 6: 2534-2549
10. Nelson MC, Story M, Larson NI i wsp.. Emerging adulthood and college-aged
youth: An overlooked age for weight-related behavior change. Obes. 2008
16:2205–2211
11. Ganasegeran K, Al-Dubai SA, Qureshi AM i wsp.. Social and psychological
factors affecting eating habits among university students in a Malaysian medical
school: a cross-sectional study. Nutr J. 2012:11:48.
12. Anand T, Tanwar S, Kumar R i wsp.. Knowledge, attitude, and level of physical
activity among medical undergraduate students in Delhi. Indian J Med Sci. 2011
65:133-42.
13. Pate RR, Pratt M, Blair SN i wsp. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995 273:402-7.
14. Milosevic M, Jovanov E, Frith KH i wsp. Preliminary analysis of physiological
changes of nursing students during training. Conf Proc IEEE Eng Med Biol Soc.
2012:3772-5.
ABSTRACT
The knowledge on risk factors of heart-vascular diseases is a significant component of these diseases' prevention. In Wroclaw Medical University, a multi-stage
study was planned, which aims at assesing the knowledge on cardiovascular diseases' risk factors and realizing recommendations of pro-healthy lifestyle among the
students of Medicine faculty. Current publication refers to pilot study conducted
among English-speaking students in Medical Faculty. 81 participants were invited to
the study. They filled in a survey specially construed for that purpose. The students
of I year ED of medical faculty are characterized by low knowledge on risk factors
for cardio-vascular diseases. The knowledge possessed by them is reflected on a
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Health and wellness
rather average level in the recommendations concerning pro-healthy lifestyle. A
majority of students conduct a sedentary lifestyle and do not comply with the dietetic recommendations. A member of the family with medical education affect the
improvement of the results achieved. In the future, the group of students being subject to analysis is to be extended.
STRESZCZENIE
Wiedza o czynnikach ryzyka chorób sercowo-naczyniowych jest istotnym
składnikiem prewencji tych chorób. W Uniwersytecie Medycznym we Wrocławiu
zaplanowano wieloetapową prace, której celem jest ocena wiedzy o czynnikach
ryzyka chorób sercowo-naczyniowych oraz realizacji zaleceń prozdrowotnego stylu
życia wśród studentów medycyny. Bieżąca publikacja dotyczy badania
pilotażowego prowadzonego wśród studentów anglojęzycznych na wydziale
lekarskim. Do badania zaproszono 81 uczestników. Wypełnili oni specjalnie
skonstruowaną ankietę badawczą. Studentów I roku ED wydziału lekarskiego
charakteryzuje niska wiedza o czynnikach ryzyka chorób sercowo-naczyniowych.
Posiadania przez studentów wiedza przeciętnie przekłada się na realizację zaleceń
dotyczących prozdrowotnego stylu życia. Większość studentów prowadzi siedzący
tryb życia i nie stosuje się do zaleceń dietetycznych. Posiadanie w rodzinie osoby z
wykształceniem medycznym wpływa na poprawę uzyskiwanych wyników. W
przyszłości planowane jest rozszerzenie grupy studentów poddanych analizie.
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