Biological Assessment and Risk Comparison (BARC) Study: Teaching RRFSS to BARC

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Biological Assessment and Risk Comparison (BARC)
Study Teaching RRFSS to BARC

• A presentation to the
• RRFSS Workshop, Toronto, Canada
• 20 June 2007

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Investigators

• Dr. Pete Kavsak
• McMaster University, ON
• Dr. Andrew MacRae
• Cadham Provincial Laboratory, MB
• Kathy Moran
• Epidemiologist, Durham Region Health Department
• David Northrup
• Institute for Social Research, York University
• Dr. Donna Reynolds
• University of Toronto, ON

3
Study Team

• Evelyn Moreau
• Study Coordinator, Lakeridge Health, ON
• Team of Study Nurses
• Bernadette Riordan
• Heather ONeill
• Francine Dion
• Kim James

4
Acknowledgment

• Funding provided by the Canadian Institutes of
  Health Research pilot project grant Population
  and Public Health Methods and Tools grant

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Background

• WHO STEPwise approach for noncommunicable disease
  surveillance
• Step I self-reported information (core
  socio-economic data, tobacco, alcohol,
  nutritional status, physical inactivity)
• Step II physical measures (height, weight, waist
  circumference, blood pressure)
• Step III biochemical measures (blood
  cholesterol, fasting blood glucose)

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BARC Objectives

• To determine the feasibility of collecting
  physical and biochemical measures
• To assess the validity of RRFSS modules
• Validity of chronic diseases module (included
  self-report blood cholesterol), current smokers
• To obtain prevalence estimates of
• High waist circumference
• High risk for cardiovascular disease/Metabolic
  syndrome

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BARC Methods

• Recruited from completions in RRFSS
• Respondents consented to a follow up telephone
  call from the Study Coordinator
• Appointment scheduled in the follow up call from
  the Study Coordinator
• Assessment completed by the Study Nurse

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Procedure Manual

• Equipment Inventory
• Calibration procedures
• Care and maintenance
• Physical measures protocol
• Biochemical measures protocol
• Cholestech LDX point-of-care device
• Correlation study
• Quality control
• Nurses training
• Data entry screens
• Data coding rules
• Safety Procedures
• Participants
• Study Nurses
• Out of range results

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Recruitment

• RRFSS
• June December 2006
• All adults 18 years and older were eligible,
  excluded pregnant women (n1,386)
• 180 completions/month
• Standard recruitment scripts for interviewers and
  the Study Coordinator
• Received weekly list of potential participants
• 359/1,386 (25.9) RRFSS completions consented to
  a follow up call
• 18/1,386 (1.2) RRFSS completions consented to a
  study package only

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Study Package

• 357/359 consented to received a study package
• Letter
• Information Sheets
• Blood cholesterol/glucose
• Blood pressure
• Body Mass Index/Waist Circumference
• Respondent Booklet

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Assessment

• Measures
• Physical measures
• sBP, dBP, height, weight, waist circumference
• Biochemical measures
• Fasting total cholesterol (TC), High density
  lipoprotein (HDL), triglycerides, low density
  lipoprotein (LDL), glucose
• Interview
• Age
• History of heart disease, diabetes, chronic
  kidney disease
• Medication Use
• Current smoking status

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Assessment cont

• Obtained signed consent
• 1 hour ( travel time of up to 1 hour)
• 250/359 (69.5) completed an assessment
• 81/359 (22.6) did not participate
• 28/359 (7.8) called and informed the study had
  ended
• Response rate 11
• 25/250 (10.0) assessments completed at the
  Health Department
• 44/250 (17.6) did not receive the information
  package
• Median time from the RRFSS interview to
  assessment was 38 days (21-68 days)

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Study Population

• Male 38, Female 62
• Mean age 52.3 years (sd 15.52)
• Median 50 years
• 18-44 35
• 45-64 41
• 65 24

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Study Population

• ltHS 14
• HS 40
• Post 2nd grad 46
• lt40k 25
• 40-70k 27
• 70-100k 18
• 100k 30
• missing 10
• Self-reported general health
• Excellent/good 56
• Good/fair 42
• Poor 2

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Criteria

• Sensitivity and Specificity
• 80 high validity
• 60 to lt80 moderate validity
• lt60 low validity
• Correlation Coefficient
• 0.60 high validity
• 0.40 to lt0.60 moderate validity
• lt0.40 low validity
• Kappa
• 0.60 high agreement
• 0.40 to lt0.60 moderate agreement
• lt0.40 low agreement

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Prevalence of Hypertension

• RRFSS Have you ever been told by a doctor or
  other health care professional that you have high
  blood pressure?
• Yes/no/dk/r
• BARC 2007 recommendations from the Canadian
  Hypertension Education Program
• 180/90 mmHg or 130/80 mmHg in individuals with
  diabetes or chronic kidney disease, or
  individuals on antihypertensive medication

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Results Hypertension
Overall Self-report Direct Sensitivity Specificity Kappa
(n250/250) hypertension 23.2 39.6 55.6 98.0 0.577
Males Males Males Males Males Males Males
(n96/96) hypertension 22.9 47.9 45.7 98.0 0.446
Females Females Females Females Females Females Females
(n154/154) hypertension 23.4 34.4 64.2 98.0 0.673
significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05
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Conclusions Hypertension

• Poor validity overall and for males
• Moderate validity for females

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Prevalence of Hypercholesterolemia

• RRFSS Have you ever been told by a doctor or
  other health care professional that your blood
  cholesterol is high? (if required, cholesterol is
  a fatty substance in your blood that can build up
  on the insides of your blood vessels)?
• Yes/no/dk/r
• BARC Prevalence of hypercholesterolemia was
  based on TC gt 5.2 mmol/L or individuals taking
  cholesterol-lower medication

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Results Hypercholesterolemia
Overall Self-report Direct Sensitivity Specificity Kappa
(n244/248) hypercholesterolemia 31.6 51.6 51.0 88.2 0.392
Males Males Males Males Males Males Males
(n92/96) hypercholesterolemia 35.9 59.4 53.7 89.5 0.399
Females Females Females Females Females Females Females
(n152/152) hypercholesterolemia 28.9 46.1 49.3 87.7 0.379
significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05
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Conclusions Hypercholesterolemia

• Poor validity in all three groups

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Prevalence of Diabetes

• RRFSS Have you ever been told by a doctor or
  other health care professional that you have
  diabetes?
• Yes/no/dk/r
• BARC 2003 recommendations from the Canadian
  Diabetes Association
• Fasting blood glucose (FBG) gt 7.00 mmol/L or
  individuals currently diagnosed with diabetes or
  taking insulin

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Results Diabetes
Overall Self-report Direct Sensitivity Specificity Kappa
(n249/240) diabetes 9.6 10.4 92.0 99.5 0.932
significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05
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Diabetes Conclusions

• High validity in estimating diabetes - overall

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Height, Weight, Body Mass Index (BMI)

• RRFSS How tall are you without shoes?
• Feet/inches/centimetres/dk/r
• RRFSS How much do you weigh?
• -pounds/kilograms/dk/r
• BARC direct measures of height and weight
• BMI categories International definitions

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Results Height, Weight, BMI
Overall Self-report Direct Spearmans rho
(n249/250) mean height (m) 1.68 1.67 0.964
(n239/250) mean weight (kg) 74.54 77.40 0.975
(n238/250) mean BMI (kg/m2) 26.17 27.67 0.946
Males Males Males Males Males
(n95/96) mean height (m) 1.77 1.75 0.951
(n95/96) mean weight (kg) 83.40 84.27 0.957
(n94/96) mean BMI (kg/m2) 26.65 27.44 0.934
Females Females Females Females Females
(n154/154) mean height (m) 1.62 1.62 0.934
(n144/154) mean weight (kg) 68.69 73.12 0.973
(n144/154) mean BMI (kg/m2) 25.86 27.82 0.943
significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05
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Results BMI Categories
Overall Self-report Direct Sensitivity Specificity
(n238/250) acceptable weight (BMI gt 18.5 and lt 25.0) 45.0 35.2 93.1 82.8
(n238/250) overweight/obese (BMI gt 25.0) 55.0 64.0 83.9 93.3
Males Males Males Males Males Males
(n94/96) acceptable weight (BMI gt 18.5 and lt 25.0) 31.9 25.0 82.6 84.5
(n94/96) overweight/obese (BMI gt 25.0) 68.1 72.9 87.0 84.0
Females Females Females Females Females Females
(n144/154) acceptable weight (BMI gt 18.5 and lt 25.0) 53.5 41.6 96.9 81.3
(n144/154) overweight/obese (BMI gt 25.0) 46.5 58.4 81.3 80.5
significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05
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Conclusions Height, Weight, BMI

• High validity for mean height, weight and BMI in
  all three groups overall, males and females
• High validity for BMI categorized as acceptable
  and combined overweight/obese in all three groups

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Why Combine?
Overall Self-report Direct Sensitivity Specificity
(n238/250) overweight (BMI gt 25.0 and lt 30.0) 37.8 38.0 70.7 82.9
(n238/250) obese (BMI gt 30.0) 17.2 26.0 66.7 98.3
Males Males Males Males Males Males
(n94/96) overweight (BMI gt 25.0 and lt 30.0) 53.2 53.1 80.0 77.3
(n94/96) obese (BMI gt 30.0) 14.9 19.8 68.4 98.7
Females Females Females Females Females Females
(n144/154) overweight (BMI gt 25.0 and lt 30.0) 27.8 28.6 59.5 85.3
(n144/154) obese (BMI gt 30.0) 18.8 29.9 65.8 98.1
significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05 significant difference between self-report and quantitative measures, p lt 0.05
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Current Smoking

• RRFSS Have you smoked at least 100 cigarettes in
  your lifetime?
• Yes/no/dk/r
• RRFSS Currently do you smoke cigarettes
  everyday, some days, or not at all?
• Everyday/some days/not at all/dk/r
• BARC Are you currently smoking?
• Yes/no

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Current Smoking Results
Overall Self-report Direct Sensitivity Specificity Kappa
(n250/250) current smoking 10.4 12.8 78.1 99.5 0.844
significant difference , p lt 0.05 significant difference , p lt 0.05 significant difference , p lt 0.05 significant difference , p lt 0.05 significant difference , p lt 0.05 significant difference , p lt 0.05 significant difference , p lt 0.05
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Waist Circumference (WC)

• 1998 recommendations from the National
  Institutes of Health
• High WC
• Males 102 cm (40)
• Females 88 cm (35)

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Results Waist Circumference
Normal WC () High WC () Total (n)
Males 84.4 15.6 96
Females 59.7 40.3 154
Total 69.2 30.8 250
significant difference, p lt 0.05 significant difference, p lt 0.05 significant difference, p lt 0.05 significant difference, p lt 0.05
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Cardiovascular Risk

• Framingham Risk Score (FRS)
• Metabolic Syndrome (MetS)
• National Cholesterol Education Program - Adult
  Treatment Panel III (ATP III)
• International Diabetes Federation (IDF)

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Framingham Risk Score

• Clinical tool for evaluating a persons 10-year
  risk of coronary artery disease
• Model to estimate risk based on the data from the
  Framingham Heart Study
• Identifies three risk categories based on age,
  sex, TC, smoking status, HDL, sBP and previous
  history of disease
• Reference Genest J, Frohlick J, Fodor G and
  McPherson R. Recommendations for the management
  of dyslipidemia and the prevention of
  cardiovascular disease 2003 update. CMAJ October
  28, 2003 169(9) online 1-10

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Metabolic Syndrome

• Clustering of cardiovascular risk factors to
  identify individuals at high risk for Type 2
  Diabetes and cardiovascular disease
• Abdominal obesity (WC)
• Hypertension
• Hyperlipidemia (TC, HDL)
• Insulin resistance (FBG)

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MetS Definitons

• National Cholesterol Education Program - Adult
  Treatment Panel III (ATP III)
• Grundy S, Brewer B, Cleeman J, Smith S and
  Lenfant C. Definition of metabolic syndrome
  Report of the National Heart, Lung, and Blood
  Institute/American Heart Association on
  scientific issues related to definition.
  Circulation 2004 109 433-438
• International Diabetes Federation (IDF)
• Alberti K, Zimmet P and Shaw J. The metabolic
  syndrome - a new worldwide definition. Lancet
  2005 366 1059-1062

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Results Cardiovascular Risk
high risk (FRS) MetS (ATP III) MetS (IDF) Kappa (ATP III IDF)
Overall (n250) 26.6 23.2 24.0 0.689
Males (n96) 38.5 26.0 22.9 0.409
Females (n154) 19.1 21.4 24.7 0.872
significant difference, p lt 0.05 significant difference, p lt 0.05 significant difference, p lt 0.05 significant difference, p lt 0.05 significant difference, p lt 0.05
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Next Steps

• Analysis pending
• Non-response study
• Costing
• Weighting
• Implications for RRFSS questions influenza
  analysis
• Physical and Biochemical measures Model for
• Further validation studies smoking, alcohol,
  physical activity
• Expand to other regions and subpopulations -
  ethnicity
• Implications for Public Health
• Hypertension, hyperlipidemia, cardiovascular
  risk, MetS
• Opportunity to partner with LHINs

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Q As