Prevalence of Selected Risk Factors for Chronic Disease --- Jordan, 2002
In Jordan, the average life expectancy in 2002 was 72 years (1), and chronic diseases are becoming increasingly prevalent (2--4). Because personal behavior can influence the occurrence and progression of many chronic diseases, the Jordan Ministry of Health (JMoH) established surveillance for behavioral risk factors, particularly those related to cardiovascular diseases and diabetes. This report summarizes the key findings of the 2002 Behavioral Risk Factor Survey, the first reporting segment in Jordan's surveillance program for chronic diseases. The findings indicate that smoking, physical inactivity, and obesity contribute substantially to the burden of chronic disease in Jordan and underscores the need for effective public health interventions.
In May 2002, a total of 28 questions about behavioral risk factors and noncommunicable disease prevalence were added to the Jordan Department of Statistics' quarterly, multistage, cross-sectional employment and unemployment survey. The sample was based on the sampling frame provided by the 1994 Jordan Population and Housing Census. The frame excluded persons living in remote areas, the majority of whom are nomads, and those living in collective dwellings (e.g., hotels, hospitals, work camps, and prisons). The sampling frame was representative nationally and stratified by governorate, major city, and other urban and rural areas. Within each stratum, sample blocks were selected systematically with probability proportional to size, and sample households were selected by using a systematic random procedure. One respondent aged >18 years was selected from each sample household and interviewed directly. All reported estimates were weighted to account for the sample design and were further adjusted for the noninterview response rate. STATA-7 software (5) was used to calculate 95% confidence intervals.
Respondents were asked whether they ever had their blood pressure or cholesterol checked by a health-care professional and whether a health-care professional had ever told them that they had high blood pressure, high cholesterol, asthma, or diabetes or that they had had a heart attack. Gestational diabetes was excluded from the analysis. Smokers were classified as "ever smokers" (i.e., smokers who had smoked >100 cigarettes during their lifetime) or "current smokers" (i.e., smokers who had ever smoked 100 cigarettes and currently smoke every day or some days). Questions on self-reported height and weight were included, and body mass index (BMI) (i.e., ratio of weight in kilograms to height in meters squared [kg/m2]) was calculated. Being overweight was classified as having a BMI of 25.0--25.9, and obesity was classified as having a BMI of >30. Respondents were asked whether they engaged in weekly moderate or vigorous activity. Moderate activity was defined as any activity that caused light sweating and small increases in heart rate or breathing for 30 minutes. Vigorous activity was defined as any activity that caused heavy sweating or large increases in heart rate or breathing for 20 minutes. Respondents also were asked when they had last sought health care from a health-care professional.
A total of 8,791 questionnaires were completed among 9,601 sampled households (response rate: 92%), excluding vacant and closed houses. The prevalence of persons who had ever had their blood pressure checked was 67% (74% of women and 61% of men) (Table). Of 6,147 respondents who ever had their blood pressure checked, 22% had been told by a health-care professional that they had high blood pressure. A total of 19% of respondents reported ever having had their blood cholesterol checked; however, this prevalence was 35% among respondents aged 50--64 years. The overall reported prevalence of diabetes was 6%; however, this prevalence increased to 20% for persons aged 50--64 years. The reported prevalence of asthma was 5% (6% of women and 4% of men), and 2% of respondents had ever been told by a health-care professional that they had had a heart attack. A total of 30% of respondents reported currently smoking cigarettes every day or some days, and 38% reported ever smoking >100 cigarettes. Nearly half (51%) of the male respondents were current smokers, compared with 8% of female respondents. Among current smokers, men smoked approximately 23 cigarettes per day, compared with 12 cigarettes a day among women. Among current smokers who had visited a health-care professional during the preceding 6 months, 43% had received counseling about smoking. The prevalence of being overweight was 32%, and the prevalence of obesity was 13% (16% of women and 10% of men). Among obese respondents who visited a health-care professional during the preceding 6 months, 26% received counseling about exercise and 34% about nutrition. The prevalence of any weekly vigorous physical activity was 32%, and 53% of all respondents reported weekly physical activity.
Reported by: F Shehab, MD, Field Epidemiology Training Program; A Belbeisi, MD, Jordan Ministry of Health. H Walke, MD, Div of International Health, Epidemiology Program Office, CDC.
Chronic disease represents a substantial health problem for residents of Jordan. Because many questions in the Jordan survey are similar to those asked in the U.S. Behavioral Risk Factor Surveillance System, the two sets of results can be compared.
In 2001, of all U.S. states and territories in the United States in which respondents were asked if a health-care professional had ever told them they had high blood cholesterol, hypertension, or diabetes, the median percentages of persons responding "yes" were 30%, 26%, and 7%, respectively (6). Reporting of high blood cholesterol was substantially higher in the United States than in Jordan. This difference might be attributable to such factors as diet and genetic predisposition; however, the substantial differences in the percentages of persons in the two countries ever checked for high blood cholesterol (19% in Jordan versus 77% in the United States) suggest that Jordanians are less likely to seek or obtain preventive services. Efforts are needed to improve awareness among patients and health-care professionals of the value of preventive health care.
The median prevalence of current smoking in the United States was 23% (26% for men and 21% for women). Smoking in Jordan among men was more prevalent, with 51% of men aged >18 years being current smokers. The low prevalence (8%) of smoking among Jordanian women probably reflects cultural norms that dissuade women from starting to smoke. Creation of primary prevention programs that promote nonsmoking among young Jordanian women might be useful in sustaining this low prevalence in the future.
The substantial levels of obesity in Jordan, especially among women, combined with the overall low physical activity levels among both sexes, reflects the need to increase opportunities for counseling on exercise and nutrition. Such counseling by health-care professionals can improve health-related choices.
The findings in this report are subject to at least three limitations. First, the survey relied only on self-reports of diagnosed diseases such as diabetes and hypertension, and many persons might have undiagnosed disease. Second, the calculated BMIs might have been affected by biases in self-reported height and weight; the validity of such measures has not been studied in Jordan. Finally, in face-to-face interviews, women might have underreported their smoking habits because of general disapproval of smoking among women in Jordan.
The survey described in this report was conducted as part of the Jordan Field Epidemiology Training Program (FETP). The Jordan FETP began in 1999 as a 2-year program within JMoH's Directorate of Disease Control. Each year, the program accepts five to seven residents who are involved primarily in outbreak investigations and projects that strengthen infectious and noncommunicable disease surveillance.
The 2002 Jordan Behavioral Risk Factor Survey highlights substantial levels of risk for chronic disease in the Jordanian population. This survey represents an important step toward establishing the regular collection of information on risk factors, which can be useful for public health-care professionals in planning and evaluating interventions. JMoH will repeat the survey in 2004 and thereafter at regular intervals. The 2004 survey will include additional questions on nutrition, maternal health, and smoking-related behavior.
This report is based on contributions by N Salem, PhD, Minnesota Dept of Health. D Holtzman, PhD, Public Health Practice Program Office; D McQueen, ScD, National Center for Chronic Disease Prevention and Health Promotion, CDC.
- Jordan Department of Statistics. Jordan in Figures. Amman, Jordan: Jordan Department of Statistics, 2002.
- Khoury SA, Massad D, Fardous T. Mortality and causes of death in Jordan 1995--1996: assessment by verbal autopsy. Bull World Health Organ 1999;77:641--50.
- Abbas AA, Khoury SA, Massad D, Karabsheh S. Prevalence of overweight and obesity in adult Jordanians aged 25 years and over: results of a national survey. Journal of the Arab Board of Medical Specializations 2002;4:90--7.
- Ajlouni K, Jaddou H, Batieha A. Diabetes and impaired glucose tolerance in Jordan: prevalence and associated risk factors. J Intern Med 1998;244:317--23.
- StataCorp. Stata Statistical Software: Release 7.0. College Station, Texas: Stata Corporation, 2001.
- CDC. State-specific prevalence of selected chronic disease-related characteristics---Behavioral Risk Factor Surveillance System, 2001. In: Surveillance Summaries (August 22). MMWR 2003;52(No. SS-8).
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