Challenges and opportunities in establishing an Health Examination Survey

In Italy, the last 30 years witnessed the implementation of cross-sectional surveys providing baseline data on numerous risk factors collected from random samples of the adult general population. In order to support those groups who would like to implement an health examination survey (HES), according to the experience of  the CUORE Project surveys, the objective of this paper is to describe some information related to the organization of a survey (examination sites and sampling, selection of analytic laboratory, coordination and personnel involved, sample selection, recruitment and appointment scheduling, informative notice and informed consent, participation rate, non-participation bias, quality assurance, survey data, long term storage of the samples, internal quality control, external quality assessment, feedback to participants, error checking, correction and documentation of the data, transfer and storage of the data, statistical analyses and interpretation of results, dissemination of results), usually shortly described  in scientific papers but relevant when an HES is planned

Prevalence and cardiovascular risk profile of chronic kidney disease in Italy: Results of the 2008-12 National Health Examination Survey

Background National surveys in countries outside Europe have reported a high prevalence (11-13%) of chronic kidney disease (CKD). Studies in Europe have provided a variable prevalence likely due to differences in study design, including age and extent of geographic areas, equation used to evaluate estimated glomerular filtration rate (eGFR) and CKD stages examined. Methods The 2008-12 National Health Examination Survey in Italy randomly extracted samples from the general population aged 35-79 years, stratified by age and gender, from the resident list of each Italian region (440 persons/1.5 million of residents). We estimated the prevalence of CKD by means of urinary albumin: creatinine ratio and eGFR (CKD-EPI equation-enzymatic assay of serum creatinine). Cardiovascular (CV) risk profile was also evaluated. Results Three thousand eight hundred and forty-eight men and 3704 women were examined. In the whole population, mean age was 57 ± 12 and 56 ± 12 years in men and women, respectively; hypertension was prevalent in men and women, respectively (56 and 43%) and the same held true for overweight (48 and 33%), obesity (26 and 27%), diabetes (14 and 9%) and smoking (21 and 18%), whereas CV disease was less frequent (9 and 6%). Overall, the prevalence of CKD (95% confidence interval) was 7.05% (6.48-7.65). Early stages constituted 59% of the CKD population [Stage G1-2 A2-3: 4.16% (3.71-4.61) and Stage G3-5: 2.89% (2.51-3.26)]. At multivariate regression analysis, age, obesity, hypertension, diabetes, CV disease and smoking were all independent correlates of CKD. Conclusions CKD has a relatively lower prevalence in Italy, in particular for advanced stages, when compared with similar national surveys outside Europe. This occurs despite older age and unfavourable CV risk profile of the whole population

Iodine Intake Estimated by 24 h Urine Collection in the Italian Adult Population: 2008–2012 Survey

Monitoring the population iodine status is essential for iodine deficiency eradication. This study assessed the average dietary iodine intake and the iodine status of a random sample of the Italian general adult population. The study population included 2378 adults aged 35–79 years (1229 men and 1149 women) from all 20 Italian regions, participating in the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey 2008–2012 (OEC/HES), and were examined for iodine intake in the framework of the MINISAL-GIRCSI Programme. Dietary iodine intake was assessed by the measurement of 24 h urinary iodine excretion. The median daily iodine intake of the whole population was lower (96 μg/d, interquartile range 51–165) than the daily adequate iodine intake according to both EFSA and WHO recommendation (150 μg/d), with a significantly lower value among women (85 μg/d) compared with men (111 μg/d). Iodine intake diminished with age and increased with BMI (body mass index) in male but not in female participants, without achieving the adequate intake in any sex, age, or BMI category. In this random sample of Italian general adult population examined in 2008–2012, iodine intake still remained lower than the recommended val- ues despite the implementation of a strategy of iodoprophylaxis based on salt iodization in 2005. These data represent a valuable reference for future monitoring of iodine status in our country

Trend of salt intake measured by 24-h urine collection in the Italian adult population between the 2008 and 2018 CUORE project surveys.

Background and aims: The WHO Global Action Plan for the Prevention of non-communicable diseases (NCDs) recommends a 30% relative reduction in mean population salt/sodium intake. The study assessed the trend in the habitual salt intake of the Italian adult population from 2008 to 2012 to 2018–2019 based on 24-h urinary sodium excretion, in the framework of the CUORE Project/MINISAL-GIRCSI/MENO SALE PIU' SALUTE national surveys. Methods and results: Data were from cross-sectional surveys of randomly selected age and sex–stratified samples of resident persons aged 35–74 years in 10 (out of 20) Italian Regions distributed in North, Centre and South of the Country. Urinary sodium and creatinine measurements were carried out in a central laboratory. The analyses included 942 men and 916 women examined in 2008–2012, and 967 men and 1010 women examined in 2018–2019. The age-standardized mean daily population salt (sodium chloride) intake was 10.8 g (95% CI 10.5–11.1) in men and 8.3 g (8.1–8.5) in women in 2008–2012 and respectively 9.5 g (9.3–9.8) and 7.2 g (7.0–7.4) in 2018–2019. A statistically significant (p<0.0001) salt intake reduction was thus observed over 10 years for both genders, and all age, body mass index (BMI) and educational classes. Conclusions: The average daily salt intake of the Italian general adult population remains higher than the WHO recommended level, but a significant reduction of 12% in men and 13% in women has occurred in the past ten years. These results encourage the initiatives undertaken by the Italian Ministry of Health aimed at the reduction of salt intake at the population level

Trend in potassium intake and Na/K ratio in the Italian adult population between the 2008 and 2018 CUORE project surveys

Abstract Background and aims Low potassium intake, in addition to high sodium, has been associated with higher risk of hypertension and CVD. The Study assessed habitual potassium intake and sodium/potassium ratio of the Italian adult population from 2008 to 2012 to 2018–2019 based on 24-h urine collection, in the framework of the CUORE Project/MINISAL-GIRCSI/MENO SALE PIU' SALUTE national surveys. Methods and results Data were from cross-sectional surveys of randomly selected age-and-sex stratified samples of resident persons aged 35–74 years in 10 (out of 20) Italian regions. Urinary electrolyte and creatinine measurements were performed in a central laboratory. Analyses considered 942 men and 916 women, examined in 2008–2012, and 967 men and 1010 women, examined in 2018–2019. In 2008–2012, the age-standardized mean of potassium intake (urinary potassium accounts for 70% of potassium intake) was 3147 mg (95% CI 3086–3208) in men and 2784 mg (2727–2841) in women, whereas in 2018–2019, it was 3043 mg (2968–3118) and 2561 mg (2508–2614) respectively. In 2008–2012, age-adjusted prevalence of persons with an adequate potassium intake (i.e. ≥ 3510 mg/day) was 31% (95% CI 28–34%) for men and 18% (16–21%) for women; in 2018–2019, it was 26% (23–29%) and 12% (10–14%) respectively. The sodium/potassium ratio significantly decreased both in men and women. Conclusions The average daily potassium intake of the Italian general adult population remains lower than the WHO and EFSA recommended level. These results suggest the need of a revision to strengthen initiatives for the promotion of an adequate potassium intake at the population level

Iodine Intake from Food and Iodized Salt as Related to Dietary Salt Consumption in the Italian Adult General Population

Since the Italian iodoprophylaxis strategy is based on the use of iodized salt, we assessed the relationship between dietary salt consumption and iodine intake in the Italian adult population. We estimated the relative contribution given by the use of iodized salt and by the iodine introduced by foods to the total iodine intake. The study population included 2219 adults aged 25–79 years (1138 men and 1081 women) from all Italian regions, participating to the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey 2008–2012 (OEC/HES), and examined for sodium and iodine intake in the framework of the MINISAL-GIRCSI Programme. Dietary sodium and total iodine intake were assessed by the measurement of 24 h urinary excretion, while the EPIC questionnaire was used to evaluate the iodine intake from food. Sodium and iodine intake were significantly and directly associated, upon accounting for age, sex, and BMI (Spearman rho = 0.298; p < 0.001). The iodine intake increased gradually across quintiles of salt consumption in both men and women (p < 0.001). The European Food Safety Authority (EFSA) adequacy level for iodine intake was met by men, but not women, only in the highest quintile of salt consumption. We estimated that approximately 57% of the iodine intake is derived from food and 43% from salt. Iodized salt contributed 24% of the total salt intake, including both discretionary and non-discretionary salt consumption. In conclusion, in this random sample of the Italian general adult population examined in 2008–2012, the total iodine intake secured by iodized salt and the iodine provision by food was insufficient to meet the EFSA adequate iodine intake

Italian network for obesity and cardiovascular disease surveillance: A pilot project

<p>Abstract</p> <p>Background</p> <p>Also in Mediterranean countries, which are considered a low risk population for cardiovascular disease (CVD), the increase in body mass index (BMI) has become a public health priority. To evaluate the feasibility of a CVD and obesity surveillance network, forty General Practitioners (GPs) were engaged to perform a screening to assess obesity, cardiovascular risk, lifestyle habits and medication use.</p> <p>Methods</p> <p>A total of 1,046 women and 1,044 men aged 35–74 years were randomly selected from GPs' lists stratifying by age decade and gender. Anthropometric and blood pressure measurements were performed by GPs using standardized methodologies. BMI was computed and categorized in normal weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25.0–29.9 kg/m²) and obese (BMI ≥ 30 kg/m²). Food frequency (per day: fruits and vegetables; per week: meat, cheese, fish, pulses, chocolate, fried food, sweet, wholemeal food, rotisserie food and sugar drink) and physical activity (at work and during leisure time) were investigated through a questionnaire. CVD risk was assessed using the Italian CUORE Project risk function.</p> <p>Results</p> <p>The percentage of missing values was very low. Prevalence of overweight was 34% in women and 50% in men; prevalence of obesity was 23% in both men and women. Level of physical activity was mostly low or very low. BMI was inversely associated with consumption of pulses, rotisserie food, chocolate, sweets and physical activity during leisure time and directly associated with consumption of meat. Mean value of total cardiovascular risk was 4% in women and 11% in men. One percent of women and 16% of men were at high cardiovascular risk (≥ 20% in 10 years). Normal weight persons were four times more likely to be at low risk than obese persons.</p> <p>Conclusion</p> <p>This study demonstrated the feasibility of a surveillance network of GPs in Italy focusing on obesity and other CVD risk factors. It also provided information on lifestyle habits, such as diet and physical activity.</p

Mild-to-Moderate Kidney Dysfunction and Cardiovascular Disease: Observational and Mendelian Randomization Analyses

BACKGROUND: End-stage renal disease is associated with a high risk of cardiovascular events. It is unknown, however, whether mild-to-moderate kidney dysfunction is causally related to coronary heart disease (CHD) and stroke. METHODS: Observational analyses were conducted using individual-level data from 4 population data sources (Emerging Risk Factors Collaboration, EPIC-CVD [European Prospective Investigation into Cancer and Nutrition-Cardiovascular Disease Study], Million Veteran Program, and UK Biobank), comprising 648 135 participants with no history of cardiovascular disease or diabetes at baseline, yielding 42 858 and 15 693 incident CHD and stroke events, respectively, during 6.8 million personyears of follow-up. Using a genetic risk score of 218 variants for estimated glomerular filtration rate (eGFR), we conducted Mendelian randomization analyses involving 413 718 participants (25917 CHD and 8622 strokes) in EPIC-CVD, Million Veteran Program, and UK Biobank. RESULTS: There were U-shaped observational associations of creatinine-based eGFR with CHD and stroke, with higher risk in participants with eG FR values 105 mL.min(-1).1.73 m(-2), compared with those with eG FR between 60 and 105 mL.min(-1).1.73 m(-2). Mendelian randomization analyses for CHD showed an association among participants with eGFR 105 mL.min(-1).1.73 m(-2). Results were not materially different after adjustment for factors associated with the eGFR genetic risk score, such as lipoprotein(a), triglycerides, hemoglobin Alc, and blood pressure. Mendelian randomization results for stroke were nonsignificant but broadly similar to those for CHD. CONCLUSIONS: In people without manifest cardiovascular disease or diabetes, mild-to-moderate kidney dysfunction is causally related to risk of CHD, highlighting the potential value of preventive approaches that preserve and modulate kidney function

Prevalence and clinical correlates of dementia among COVID-19-related deaths in Italy

Introduction: We aimed at exploring the proportion of patients dying with COVID-19 and concomitant dementia in Italy, as well as their clinical characteristics and trajectories of care. Methods: The proportion of COVID-19-related deaths occurring in people with dementia and the clinical characteristics of deceased individuals according to their dementia status were explored by considering the medical charts of a representative sample of patients deceased in Italian hospitals (n = 2621). Results: A total of 415 individuals with dementia were identified in the study population, accounting for 15.8% of overall COVID-19-related deaths. Patients with dementia less frequently presented with cough, had lower chance of receiving supportive therapies and intensive care approaches, and showed a faster clinical worsening as compared with individuals with intact cognition. Discussion: Dementia confers a relevant risk of adverse outcomes in case of SARS-CoV-2 infection and influences the clinical presentation, course and management of affected individuals

Prevalence and Correlates of Statin Underuse for Secondary Prevention of Cardiovascular Disease in Older Adults 65-79 Years of Age: The Italian Health Examination Survey 2008-2012

Limited data are available on the prevalence and correlates of statin use for secondary cardiovascular (CV) prevention in the older adult population. We used data of older adults (65-79 years) with established atherosclerotic CV disease from the cross-sectional Italian Health Examination Survey 2008-2012 to address this issue. Lifestyles, CV risk factors, chronic diseases, and therapies were assessed using standardized procedures. A comprehensive geriatric assessment was performed to evaluate cognitive function, disability in basic activities of daily living/instrumental activities of daily living, mobility, and polypharmacy. Multiple regression analyses were performed to identify independent correlates of statin use. A total of 392 participants (mean age 72.1 +/- 4.4 years, 61.5% men) were considered for this analysis. Coronary heart disease was identified in 67.1% of participants, cerebrovascular disease in 23.5%, and peripheral artery disease (PAD) in 18.1%. One hundred ninety (48.5%) were statin users. By multiple regression analysis, functional disability (odds ratio [OR] = 0.81; 95% confidence interval [CI] = 0.71-0.92; p = 0.002), cognitive impairment (OR = 0.87; 95% CI = 0.78-0.98; p = 0.018), and polypharmacy (OR = 0.86; 95% CI = 0.75-0.98; p = 0.035) predicted statin nonuse, whereas having hypertension (OR = 1.19; 95% CI = 1.05-1.34; p = 0.005), diabetes mellitus (OR = 1.14; 95% CI = 1.03-1.27; p = 0.013), or a previous myocardial revascularization (OR = 1.31; 95% CI = 1.16-1.48; p < 0.001) predicted statin use. Significant interaction terms were observed between cerebrovascular disease, PAD, cognitive impairment, and disability in predicting statin nonuse. Statin underuse in older adults aged 65-79 years with CV disease, and thus suboptimal secondary CV prevention, is highly prevalent despite current guidelines and recommendations. Common geriatric conditions are associated with statin nonuse. Such results support the need for improving the awareness of statin treatment for secondary CV prevention