ATTICA Epidemiological Study Research Articles

The burden of cardiovascular disease and related risk factors in Greece: the ATTICA epidemiological study (2002–2022)

ObjectiveThe aim of this study was to present the burden of cardiovascular disease (CVD) and its related risk factors based on a 20-year observation period (2002–2022). MethodsIn 2002, 3042 Greek adults (aged: 45 (12) years) free of CVD, cancer, or any other chronic infections were enrolled. In 2022, the 20-year follow-up was performed on 2169 participants (1988 had complete data for CVD). Lifetime risk for CVDs and disability-adjusted-life-years (DALYs) lost were also calculated. ResultsThe 20-year CVD incidence was 3600 cases/10,000 individuals (man-to-woman ratio 5:4). At the index age of 40 years, the lifetime risk for developing CVD was 68% for men and 63% for women; as the participants were getting older, the lifetime risk declined by approximately 19% and 13% for men and women, respectively, but remained at high levels, reaching 55% for both sexes. Participants between 45 and 55 years exhibited the highest CVD burden concerning aggregated DALYs. The burden was greater in men than in women, at ages below 35 years; beyond this age threshold, this trend shifted, and women exhibited a higher CVD burden. ConclusionThe burden of CVD in Greece has shown increasing trends over the past 20 years as a result of the accumulative growth of the prevalence of modifiable CVD risk factors. The disability-adjusted life-years lost are the most observed ever before, urging for efficient public health strategies and measures.

Increased body weight and central adiposity markers are positively associated with the 20-year incidence of cardiovascular disease: The ATTICA epidemiological study (2002–2022)

Increased adiposity predisposes to cardiovascular disease (CVD). We hypothesized that the presence of obesity would be positively associated with CVD risk, and that the co-presence of central obesity would modify/enhance this association. This was a prospective study (2002–2022) among 1845 Greek adults (mean age, 44.8 ± 13.5 years; men, 49.8%). At baseline, the presence of overweight/obesity was assessed via body mass index (BMI), whereas central obesity was defined as waist circumference ≥102/88 cm, waist-to-hip-ratio ≥0.95/0.80, or waist-to-height-ratio ≥0.50 in men/women. BMI was reevaluated at 10 years and longitudinal BMI trajectories (2002–2012) were identified. CVD incidence was recorded at 20 years (ratio of new cases to the number of participants assessed). Compared with participants with normal weight at baseline, those with obesity exhibited a 27% higher 20-year CVD risk after adjustment for age, sex, lifestyle habits, and medical status (hazard ratio, 1.271; 95% confidence interval, 1.012–1.597). In similar multiadjusted models, compared with participants who were always non-overweight/obese, those who were always overweight/obese exhibited a 40% higher 20-year CVD risk (hazard ratio, 1.403; 95% confidence interval, 1.018–1.936). Additional control for high-sensitivity C-reactive protein attenuated the associations. In the combined baseline body weight classification analysis, CVD incidence was the lowest in participants with normal weight without central obesity, moderate in those with overweight/obesity without central obesity, and highest in those with normal weight and central obesity and overweight/obesity and central obesity (P < .001). Obesity leads to increased CVD risk, partly mediated by inflammation. The combination of BMI with simple measures of abdominal adiposity is superior for CVD risk screening.

Cognitive vulnerability, anxiety, and physical well-being in relation to 10-year cardiovascular disease risk: The ATTICA epidemiological study.

This study aimed to evaluate the association between irrational beliefs and the 10-year cardiovascular disease (CVD) incidence among apparently healthy adults. The ATTICA study is a population-based, prospective cohort (2002-2012) consisting of 853 participants without evidence of CVD (453 men and 400 women) who underwent psychological evaluations. Participants completed the Irrational Beliefs Inventory (IBI, range 0-88), a self-reported measure consistent with the Ellis model of psychological disturbance. We conducted a factor analysis to develop irrational beliefs factors to evaluate the association between subcategories of irrational beliefs and CVD incidence. Demographic characteristics, detailed medical history, other psychological factors, and dietary and other lifestyle habits were also evaluated. The incidence of CVD was defined according to the International Coding Diseases (ICD)-10 criteria. The identified dominant irrational beliefs factor, "cognitive vulnerability to anxiety," consisted of demandingness, perfectionism, emotional irresponsibility, anxious overconcern, dependence on others, and overconcern for the welfare of others, was strongly associated with an increased 10-year CVD risk. Nested multi-adjusted regression analysis revealed that anxiety, as well as negative physical well-being, mediated this relationship, and subset of irrational beliefs predicted CVD risk directly and indirectly through anxiety and negative physical well-being. These findings further map the path through which irrational beliefs can contribute to CVDs and provide insights in favor of preventive healthcare.

Food Compass Score and its association with inflammatory markers and homocysteine in cardiovascular disease-free adults: a cross-sectional analysis of the ATTICA epidemiological study.

Several nutrient profiling systems have been developed to assist in food choices and policy. Food Compass Score (FCS) is a novel holistic food score assessing 54 parameters. The aim was to assess the relation of FCS with inflammatory and lipid markers in cardiovascular disease-free volunteers. Information from the ATTICA epidemiological study participants, with complete data on lipid, inflammatory markers and dietary intake were studied (n = 1018). C-reactive protein (CRP) and amyloid A were determined by immunonephelometry, fibrinogen by nephelometry, homocysteine by fluorometry, while tumor necrosis factor-a (TNF-a), interleukin-6 (IL-6), adiponectin and leptin were determined by ELISA in fasting blood samples. Dietary intake was assessed through a semi-quantitative validated food frequency questionnaire. Each food was assigned a FCS value from the published values and then individual's FCS values were calculated. Mean FCS was 56 (standard deviation: 5.7) and it was similar in men and women. FCS was inversely correlated with age (r = -0.06, p = 0.03). In multiple linear regression models, FCS was inversely associated with CRP (-0.03, 0.01), TNF-a (-0.04, 0.01), amyloid A (-0.10, 0.04) and homocysteine (-0.09, 0.04) (b coefficients, standard errors, all p < 0.05) and was not associated with IL-6, fibrinogen, adiponectin, leptin, or lipids levels (all p > 0.05). The inverse correlations of the FCS with inflammatory markers suggest that a diet containing foods with high FCS might be protective against inflammation process. Our results support the usefulness of the FCS, but future studies should evaluate its relation to cardiovascular and other inflammation-related chronic diseases.

The Spatial Variability of the Sex and Age- Specific 10-Year Incidence of Cardiovascular Diseases and its Clinical Risk Factors in Athens Metropolitan Area: a Local Statistical Modelling Approach in the Context of the ATTICA Epidemiological Study

According to the published European public health policies, emphasis should be given on the identification of high-risk areas, in terms of both Cardiovascular Diseases (CVDs) incidence, as well as of its main clinical risk factors. Thus, we aimed to investigate: (a) the geographical variability of the sex and age-specific 10-year incidence of CVDs and its clinical risk factors in the Athens metropolitan area, the most urbanised city in Greece accounting for about 35% of the total Greek population, and (b) the spatial heterogeneity of the association between the main clinical risk factors and the 10-year CVD incidence at an aggregated level. Data regarding the 10-year CVD incidence (% of population in each municipality with any CVD after the 10-year period), as well as the prevalence of the risk factors (obesity, hypertension, diabetes mellitus, hypercholesterolaemia; expressed as % of population in each municipality) were provided by the ATTICA epidemiological study for 2020 individuals found during the 10-year follow-up with complete data for locality geocoding. Socio-economic, demographic, and environmental characteristics for each municipality of the Attica region, were obtained from official national and international databases. A local statistical modelling approach, namely the Geographically Weighted Regression, was implemented in order to investigate the associations at a local level and therefore give emphasis on the design of more effective public health programs, taking into account the special characteristics of each area. Hypercholesterolaemia was found to be the most prevalent clinical risk factor in the study area, while higher prevalence for all the risk factors were presented in areas of lower socioeconomic status (SES), where a significantly higher number of new CVD cases in the decade were detected as well. 10-year CVD incidence was also found to be significantly elevated in areas characterized by worse health status in terms of the risk factors’ prevalence, while the sex and age- specific CVD incidence rates were found to be differently affected by these factors. Interestingly, despite the fact that CVDs are acknowledged as a man’s disease, areas of higher (South & North) and moderate (East) SES were found to be characterized by higher CVD incidence rates in females, while in areas of lower SES (West), higher CVD incidence rates were found in males. In line with the current European policy, the identification of areas where the intensity of the studied associations is stronger, can be considered a crucial methodological aspect for the design and implementation of more effective CVD prevention programs at the community level.

The synergistic role of irrational beliefs and health anxiety regarding family history of diabetes on type 2 diabetes; the attica epidemiological study

The synergistic role of irrational beliefs and health anxiety regarding family history of diabetes on type 2 diabetes; the attica epidemiological study

Irrational beliefs and health anxiety in relation to hypertension, hypercholesterolemia and lifestyle behaviors; The attica epidemiological study

Background and Aims : To evaluate the association between psychological characteristics (irrational beliefs and health anxiety), medical conditions and lifestyle behaviors, among apparently healthy adults.

Psychological factors in relation to the 10-year incidence of metabolic syndrome: The ATTICA epidemiological study (2002–2012)

Background and aimsVarious bio-psychological mechanisms underlying the association between mental health problems and metabolic syndrome remain unknown. We investigated the role of irrational beliefs in conjunction with anxiety, depression and hostility in the 10-year metabolic syndrome (MetS) incidence, and the effect of biochemical and socio-behavioral factors on the aforementioned associations. Methods and resultsATTICA is a prospective, cohort study (2002–2012). The sample included 591 participants [51.3% men (aged 41.5 ± 10 years) and 48.7% women (aged 37.5 ± 11.5 years)], free of MetS at baseline. Detailed biochemical, clinical, and lifestyle evaluations were performed, while participants’ irrational beliefs, anxiety, depression and hostility were assessed using the Irrational Beliefs Inventory, the Spielberger State-Trait Anxiety Inventory, the Zung Self-Rating Depression Scale and the Hostility and Direction of Hostility Questionnaire, respectively. Multiple logistic regression was applied to estimate the odds ratio (OR) of developing MetS and to control for confounders, as well as stratified logistic regression to detect moderator effects. High irrational beliefs were associated with 1.5-times higher odds of developing MetS than low irrational beliefs. Especially, participants with high irrational beliefs and high anxiety were 96% more likely to develop MetS, compared with those with low irrational beliefs and low or high anxiety (OR = 1.96; 95% CI = 1.01, 3.80). ConclusionThe findings of the study underline the important role of irrational beliefs and anxiety in the development of MetS and the need to build new holistic approaches focused on the primary prevention of both mental health and MetS.

Irrational beliefs, depression and anxiety, in relation to 10-year cardiovascular disease risk: the ATTICA Epidemiological Study

ABSTRACT Background and Objectives Various bio-psychosocial mechanisms underlying the link between anxiety, depression and cardiovascular disease risk, remain unknown. We investigated the role of irrational beliefs in conjunction with anxiety and depression in the 10-year cardiovascular disease (CVD) incidence, and the effect of biochemical and socio-behavioral factors. Design 853[453 men (45 ± 13 years) and 400 women (44 ± 18 years)] from the ATTICA study (2002–2012) and without evidence of CVD were assessed. Methods The Irrational Beliefs Inventory (IBI), the Zung Self-Rating-Depression-Scale (ZDRS) and the State-Trait-Anxiety-Inventory (STAI) were used for the assessments. Incidence of CVD was defined according to the International Coding Diseases (ICD)−10 criteria. Results Participants with high irrational beliefs and anxiety symptoms had a 138% greater risk of developing CVD during the 10-year follow-up (2.38; 95%CI 1.75, 3.23) as compared to those without anxiety. Among others, C-reactive protein, interleukin-6 and total antioxidant capacity were mediators in the tested association. Interaction of irrational beliefs and depression was not associated with the 10-year CVD in all models. Conclusions Inflammation and oxidative stress, partially explained the associations between irrational beliefs and anxiety in predicting CVD risk. These findings advance psychological research in the area of primary prevention of mental health and cardiovascular diseases.

Geographical Variability of Sex-Specific, Health Related Determinants of Quality of Life in Athens Metropolitan Area: A Spatial Analysis in the Context of the ATTICA Epidemiological Study

Geographical Variability of Sex-Specific, Health Related Determinants of Quality of Life in Athens Metropolitan Area: A Spatial Analysis in the Context of the ATTICA Epidemiological Study

Irrational beliefs as a major risk factor for type 2 diabetes, among people away from the Mediterranean diet; the Attica epidemiological study.

Background and Aims: To evaluate the association between irrational beliefs by Ellis and the dietary habits away from the Mediterranean diet in the 10-year incidence of type 2 diabetes.

Irrational beliefs trigger depression symptoms in relation to the 10-year cardiovascular disease risk; The Attica epidemiological study (2002-2012).

Background and Aims: To evaluate the association of psychological conditions (i.e., irrational beliefs and depression) and educational status with the 10-year cardiovascular disease (CVD) risk, among apparently healthy adults.

Irrational beliefs triggers depression and anxiety symptoms, and increase inflammation and oxidative stress surrogate markers of cardiovascular disease risk; The Attica epidemiological study (2002-2012).

Irrational beliefs triggers depression and anxiety symptoms, and increase inflammation and oxidative stress surrogate markers of cardiovascular disease risk; The Attica epidemiological study (2002-2012).

The socioeconomic and environmental determinants of the metabolic syndrome in the Athens metropolitan area: A spatial analysis in the context of the Attica epidemiological study

Background and Aims: According to the World Health Organization, the prevalence of the metabolic syndrome (MetS) is increasing rapidly worldwide, affecting approximately 20% of the global population. The present study aimed at investigating the spatial variability of the MetS’s prevalence and at identifying its socioeconomic and environmental determinants.

Socio-economic and environmental determinants of diabetes mellitus in the Athens metropolitan area: A spatial analysis in the context of the Attica epidemiological study

Background and Aims: According to the World Health Organization, over 60 million people have diabetes in Europe, while its prevalence is steadily rising. The aim of the present study was to examine the effect of socio-economic and environmental characteristics of the residential area on the prevalence of diabetes mellitus in men and women living in the Athens metropolitan area.

A spatial analysis of behavioral risk factors for cardiovascular diseases, in the context of the Attica epidemiological study in Greece

Background and Aims: Smoking, physical inactivity and unhealthy dietary behaviours constitute some of the most important modifiable risk factors for cardiovascular diseases. The aim of the present study was to detect the areas of the Athens metropolitan area where there is an increased prevalence of the specific unhealthy behaviours.

Irrational beliefs trigger depression and anxiety symptoms, and associated with increased inflammation and oxidative stress markers in the10-year diabetes mellitus risk: the ATTICA epidemiological study.

To investigate the combined role of irrational beliefs, anxietyand depression in the 10-year incidence of type 2 diabetes, and the underlying effect of biochemical, and socio-behavioural factors. Within the context of the ATTICA cohort study (2002-2012), 853 participants without evidence of CVD [453 men (45 ± 13years) and 400 women (44 ± 18years)] underwent psychological evaluation through the Irrational Beliefs Inventory (IBI) (range 0-88), the Zung Self-Rating-Depression-Scale (ZDRS) and the State-Trait-Anxiety-Inventory (STAI). Diagnosis of diabetes at follow-up examination was based on the criteria of the American Diabetes Association (ADA). Mean IBI score was 53 ± 10 in men and 51 ± 11 in women (p = 0.68). Participants with high irrational beliefs who also had anxiety symptoms had a 93% excess risk of developing diabetes during the 10-year follow-up (Hazard Ratio 1.93; 95%CI 1.34, 2.78) as compared to those without anxiety. Moreover, diabetes risk was 73% higher among individuals with highlevels of irrational beliefs and depression as compared to those where depression was absent (1.73; 1.21, 2.46). Lower education status, family history of diabetes, hypercholesterolemia, high BMI, as well as tumor necrosis factor and total antioxidant capacity were revealed as mediating risk factors related to the tested associations. Irrational beliefs among apparently healthy adults trigger depression and anxiety symptomatology, and through the increased inflammation and oxidative stress profile, were associated with increased diabetes risk. This observation moves psychological research a step forward in supporting and guiding primary prevention of mental health and metabolic conditions.

Foods, Nutrients and Dietary Patterns in Relation to Irrational Beliefs and Related Psychological Disorders: The ATTICA Epidemiological Study

We explored the differences in dietary habits and dietary patterns between individuals characterized by irrational beliefs with no or low anxiety and depressive symptoms and individuals characterized by irrational beliefs with high anxiety and depressive symptomatology. Within the context of the ATTICA cohort study (2002–2012), 853 participants without evidence of cardiovascular disease (453 men (45 ± 13 years) and 400 women (44 ± 18 years)) underwent mental health assessment through the irrational beliefs inventory (IBI), the Zung self-rating depression scale (ZDRS) and the state–trait anxiety inventory (STAI). Demographic characteristics, a thorough medical history, dietary behaviour and other lifestyle behaviours were also evaluated and analysed using factor analysis. Five main factors related to dietary patterns were extracted for the high-IBI/low-STAI group of participants (explaining the 63% of the total variation in consumption), whereas four factors were extracted for the high-IBI/high-STAI participants, the high-IBI/low-ZDRS participants and the high-IBI/high-ZDRS participants, explaining 53%, 54% and 54% of the total variation, respectively. A Western-type dietary pattern was the most dominant factor for individuals reporting irrational beliefs and anxiety or depressive symptomatology. The high refined carbohydrates and fats dietary pattern was the most dominant factor for individuals with irrational beliefs but without psychopathology. Linear regression analysis showed that irrational beliefs, in combination with anxiety or depression, age, sex and BMI, were important predictors of adherence to the Mediterranean diet. Dietary habits interact with irrational beliefs and, in association with the consequent psychological disorders, are associated with overall diet, and presumably may affect the health status of individuals.

The relationship of the built and food environments with the metabolic syndrome in the Athens metropolitan area: a sex-stratified spatial analysis in the context of the ATTICA epidemiological study

The built and food environments are widely acknowledged to play an important role in defining human health by influencing, among others, behaviors such as nutrition habits and physical activities. The aim of this study was to identify the spatial variability of the sex-specific prevalence of the metabolic syndrome (MetS) and its environmental determinants in the Athens metropolitan area. Data on the prevalence of the MetS were provided by the ATTICA epidemiological study for 2749 participants, with complete data for geographical identification (1375 women [44years old {SD = 14years}] and 1374 men [45years old {SD = 13years}]), while socioeconomic, demographic, and environmental characteristics were provided by official national and international databases. Approximately 20% of the people residing in the study area were diagnosed with MetS, with its prevalence being almost two times higher in men compared to women. Areas more extensively covered by green urban spaces and sports facilities were shown to have a lower prevalence of MetS, while greater density and availability of supermarkets and street markets were inversely related to MetS prevalence in both sexes. In addition, the present analysis revealed that the beneficial role of the built environment's characteristics on MetS prevalence was significantly stronger in the male population, while the preventive effect of the food environment's characteristics was almost 1.5 times stronger in the female population CONCLUSION: Although individualized prevention and treatment approaches are necessary to decrease the burden of MetS, environmental modifications that promote healthy behaviors represent an essential health approach.

Socio- Demographic, Clinical and Lifestyle Determinants of Low Response Rate on a Self- Reported Psychological Multi-Item Instrument Assessing the Adults’ Hostility and its Direction: ATTICA Epidemiological Study (2002-2012)

Background: Missing data constitutes a common phenomenon, especially, in questionnaire-based, population surveys or epidemiological studies, with the statistical power, the efficiency and the validity of the conducted analyses being significantly affected by the missing information. The aim of the present work was to investigate the socio-demographic, lifestyle and clinical determinants of low response rate in a self- rating multi-item scale, estimating the individuals’ hostility and direction of hostility. Methods: 3042 apparently healthy volunteers residing in the Athens metropolitan area participated in the ATTICA epidemiological study [1514 (49.8%) were men [46 years old (SD= 13 years)] and 1528 (50.2%) were women [45 years old (SD= 14 years)]]. Hostility and Direction of Hostility was assessed with the Hostility and Direction of Hostility (HDHQ) scale. Binary logistic regression with backward model selection was used in order to identify the key demographic, clinical and lifestyle determinants of higher non-response rate in the HDHQ scale. Results: The vast majority of the participants (87.0%) had missing information in the HDHQ scale. Older age, lower educational level, poorer health status and unhealthy dietary habits, were found to be significant determinants of high nonresponse rate, while female participants were found to be more likely to have missing data in the items of the HDHQ scale. Conclusions: The present work augments prior evidence that higher non-response to health surveys is significantly affected by responders’ background characteristics, while it gives rise to research towards unrevealed paths behind this claim.