Asian Nursing Research 6 (2012) 1e8

Contents lists available at SciVerse ScienceDirect

Asian Nursing Research

journal homepage: www.asian-nursingresearch.com

Research Article

Cardiovascular Risk Factors and 10-year Risk for Coronary Heart Disease
in Korean Women
Sunjoo Boo, RN, PhD *, Erika Sivarajan Froelicher, RN, PhD, FAAN
Department of Physiological Nursing, University of California, San Francisco, California, USA

a r t i c l e i n f o s u m m a r y

Article history: Purpose: The purpose of this study is to describe the prevalence of cardiovascular risk factors and to
Received 17 August 2011 estimate the 10-year risk for coronary heart disease (CHD) in a nationally representative sample of
Received in revised form Korean women.
13 February 2012
Methods: This is a secondary data analysis using the data set from the 2008 Korea National Health and
Accepted 15 February 2012
Nutrition Examination Survey IV. The sample was 2,998 Korean women (weighted n ¼ 14,420,987) aged
20e79 years without cardiovascular disease or diabetes. Prevalence of cardiovascular risk factors was
calculated using sampling weights and presented in percentages. Ten-year risk for CHD was estimated
Keywords:
coronary heart disease
with the Framingham Risk Score, and the proportions for three levels of 10-year risk were presented.
Korea Results: About 18% of the sample had hypertension, 7.5% are current smoker, 30.0% had total
risk assessment cholesterol  200 mg/dL, 25.7% had low-density lipoprotein cholesterol  130 mg/dL, and 47.3% had
risk factors high-density lipoprotein cholesterol < 50 mg/dL. About 46% of Korean women were overweight or
women obese, and 33.3% were sedentary. About 75% of women had one or more major risk factors. In this study
sample, 98.5% had a 10-year risk for CHD of < 10%, 1.4% had a risk of 10e20%, and 0.1% had a risk
of > 20%.
Conclusion: Modifiable cardiovascular risk factors are highly prevalent in Korean women, and the
combination of risk factors is common. Development and implementation of multifaceted nursing
interventions are required to confront the current epidemic rise of CHD in Korean women.
Copyright Ó 2012, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.

Introduction Primary prevention of CHD requires an accurate assessment of

Although cardiovascular disease (CVD) has been considered
a disease of men in Korea, women can and do get CVD. In fact, more
women than men die of CVD in Korea, accounting for 1 in 4.5
deaths in women in 2009, compared to 1 in 5.8 in men in 2009
(Korea National Statistical Office, 2010). Of important concern to
Korean women is the dramatically increasing mortality rate from
coronary heart disease (CHD). Between 1983 and 2009, mortality
from CHD increased approximately 15-fold in Korean women
(Korea National Statistical Office). Furthermore, current projections
suggest a continued increase in CHD with the aging population and
a westernized lifestyle and diet (Kim, Kim, Jung, Park, & Park, 2007;
Lee et al., 2007). There is no doubt that occurrence of CHD has
become a significant burden in Korean women, and primary
prevention of CHD should be a public health priority.
* Correspondence to: Sunjoo Boo, RN, PhD student, School of Nursing, University
of California San Francisco, San Francisco, California, 94143-0610 USA.
E-mail address: sunjoo.boo@gmail.com (S. Boo).
CHD risk and identification of those at high risk for future cardiac
events and in need of preventive care (Adult Treatment Panel III
[ATP III], 2001; Grundy et al., 2004). CHD occurs in individuals
with cardiovascular risk factors. The major risk factors include
hypertension, diabetes, dyslipidemia, and cigarette smoking. These
risk factors have been considered causal to CHD because of their
independent, reproducible, temporal, and dose-response relation-
ship to the development of CHD (Wilson et al., 1998; Yusuf, Reddy,
Ounpuu, & Anand, 2001). The major risk factors are suitable for
widespread clinical use because they are common, measurable at
low cost, and, importantly, modifiable. In addition to the major risk
factors, lifestyle factors such as obesity and physical inactivity have
the potential to increase the risk for CHD by elevating blood pres-
sure, glucose, or lipids (Wilson et al.; Yusuf et al.). Lifestyle factors
are also important in terms of risk reduction because lifestyle
modification constitutes the direct target for nursing intervention
and is an integral part of long-term CHD risk reduction (ATP III;
Mosca et al., 2007).
Cardiovascular risk factors are associated with each other and
have a multiplicative rather than additive effect on health. Even

1976-1317/$ e see front matter Copyright Ó 2012, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
doi:10.1016/j.anr.2012.02.001
2 S. Boo, E.S. Froelicher / Asian Nursing Research 6 (2012) 1e8
slight elevations in two or more risk factors noticeably increase the
risk for CHD (Smith, 2007). Thus, assessment of the overall effect of
multiple risk factors on the development of CHD is crucial for
accurately identifying women at high CHD risk. Office-based risk
assessment tools help to assess multiple risk factors simultaneously
rather than focusing on any single risk factor. Among several tools
available (e.g., Reynold Risk Score, Systemic Coronary Heart Eval-
uation), the Framingham Risk Score (FRS) is the most commonly
used and most extensively validated CHD risk assessment tool. It is
a mathematical model predicting the probability of developing
CHD in the next 10 years with the major risk factors (ATP III, 2001;
Wilson et al., 1998). Current evidence-based clinical guidelines for
CHD prevention in the United States recommend estimating 10-
year risk for CHD with the FRS as an initial step in primary
prevention of CHD (ATP III; Mosca et al., 2007).
The nurses’ role includes patient and public education. Addi-
tionally nurses are actively involved with CHD risk reduction.
Effective risk reduction requires an accurate estimation of CHD risk
to more precisely select those needing nursing interventions and
health education. It also ensures better and cost-effective use of
limited resources. Given the current epidemic of CHD in Korean
women, an important opportunity exists to screen for cardiovas-
cular risk factors and estimate the 10-year risk for CHD in Korean
women in order to prevent CHD. Comprehensive risk assessment
for CHD not only describes the total burden of CHD but may also be
useful for highlighting the potential for nursing interventions to
reduce the burden of CHD. This can serve as important baseline
information for public health planning. Therefore, the research
purposes of this study were to (a) describe the prevalence of
cardiovascular risk factors (hypertension, smoking, dyslipidemia,
obesity, and physical inactivity), (b) describe the prevalence of
combinations of risk factors, and (c) estimate the 10-year risk for
CHD using the FRS in a nationally representative sample of Korean
women.
Methods
Study design and data source
This is a secondary data analysis study using data from the 2008
Korea National Health and Nutrition Examination Survey IV
(KNHANES IV) collected by the Korea Centers for Disease Control
and Prevention (KCDC). Permission to use the data set was granted
by KCDC free of charge, after reviewing the proposal of this study.
The SPSS data set and the data directory were directly downloaded
from the KCDC website (http://knhanes.cdc.go.kr/).
Sample and data collection procedure of original survey
The sample for the KNHANES IV was obtained through a strati-
fied, multistage probability sampling design to represent
community-residing Koreans (KCDC, 2008). Households were
randomly sampled, and each individual within the household was
interviewed separately. Selected households received a letter from
the KCDC director introducing the survey. They were approached
by trained interviewers to schedule a day to obtain written consent
and to schedule personal interviews and physical examinations. On
the scheduled day, upon obtaining informed written consent,
health interviews and physical measurements were performed in
a specially designed mobile center or in public health centers. The
interview included questions about demographic, socioeconomic,
medical history, and comorbid conditions. Information on health
behaviors such as smoking and physical activity was collected via
self-administered questionnaires. The health examination portion
consisted of medical and physiological measurements including
blood pressure (BP), height, and weight as well as laboratory tests.
This process took an average of 60e100 minutes to complete;
participants were encouraged to ask for assistance if needed. To
encourage participation, compensation (snacks and KRW 10,000,
corresponding to US $8.7) and a copy of the medical findings report
were given to each participant. The response rate for the original
survey was 77.8% (KCDC, 2008).
Sample for present study
The sample for this study was limited to women who completed
the survey, did not have CVD or diabetes, and were aged 20e79
years, because the FRS was devised for people in this age range
without CVD or diabetes. CVD was defined as self-reported
myocardial infarction, angina pectoris, or stroke. Diabetes was
defined as self-reported history of diabetes, or use of glucose
lowering medications, or a fasting blood glucose  126 mg/dL
(American Diabetes Association, 2010). Women who were pregnant
or lactating were excluded from the analyses because pregnancy or
lactation may influence BP, blood sugar, or body mass index (BMI).
To determine if a woman was pregnant or lactating, self-report
were used.
Of the 5,374 women participants in the original KNHANES IV
survey, 3,956 women were aged 20e79 years. After applying the
inclusion/exclusion criteria, 3,132 women were eligible for the
analysis of this study. Among them, 89 women did not fast for at
least 8 hours prior to the blood tests. Because lipid levels for those
who fasted less than 8 hours are unreliable, they were excluded
from the analysis of this study. Low-density lipoprotein cholesterol
(LDL-C) was not directly measured in the original study, so it was
estimated with the Friedewald equation for this study. The equa-
tion is unreliable and invalid when triglycerides are over 400 mg/dL
(Friedewald, Levy, & Fredrickson, 1972). Forty-five women had
triglyceride levels > 400 mg/dL; therefore, these women were
excluded yielding a final sample of a 2,998 women for the analysis
of this study.
Measurements and variables
Demographics and cardiovascular risk factors
Demographics such as age, marital status, educational level,
work status, household income, menopausal status, and meno-
pausal age were reviewed and included in this study to describe the
sample characteristics. Below poverty level was defined as the
household income levels below the Minimum cost of Living set by
Health and Welfare in Korea.
Participants were considered smokers if they reported that they
were currently smoking. BPs were measured three times, and the
average of the second and third BP readings was used for this study.
Participants were also asked whether they were currently taking
antihypertensive medications. Hypertension was defined as
a BP  140/90 mmHg or taking antihypertensive medications
(Chobanian et al., 2003). Fasting lipid levels were analyzed in
a national laboratory, and a total cholesterol  200 mg/dL, HDL-
C < 50 mg/dL, LDL-C level  130 mg/dL, and triglyceride
level  150 mg/dL were defined as risk factors for CHD in this study
(Mosca et al., 2007). Overweight was defined as BMI  23 kg/m2
(WHO, 2000). Physical activity was self-reported with the Korean
version of the International Physical Activity Questionnaire (IPAQ)
(Craig et al., 2003). Data collected with the IPAQ were scored in
MET-minutes/week for the present study (IPAQ, 2003) (metabolic
equivalent [MET]; 1 MET ¼ the rate of energy expenditure while
at rest). At least 30 minutes of moderate activity 3 days a week
can benefit CHD prevention. This amount of physical activity is
approximately 600 MET-minutes/week (IPAQ). Women with less
 S. Boo, E.S. Froelicher / Asian Nursing Research 6 (2012) 1e8 3

than 600 MET-minutes/week were considered sedentary in this Table 1 Demographic Characteristics of Korean Women Aged 20e79 Years Without
study. To present the prevalence of combination of risk factors, the Cardiovascular Diseasea or Diabetes (n ¼ 2,998, Weighted n ¼ 14,420,987)

number of major risk factors included in the FRS (hypertension,

Demographics characteristics M or % (SE)
HDL < 50 mg/dL, total cholesterol  200 mg/dl, and smoking) was
Age (yr) 43.7 (0.4)
counted. Marital status (married and living together) 67.7 (1.3)
Education (high school or less) 72.4 (1.3)
Ten-year risk for CHD Work status (yes) 49.3 (1.2)
Below poverty level 19.7 (1.1)

Given that there is no specific risk assessment tool for Korean
women, the widely used FRS was used to estimate Korean women’s
10-year risk for CHD. It estimates a women’s risk of having a first
heart attack in the next 10 years using seven variables: age, sex,
total cholesterol, HDL-C, smoking status, systolic BP and whether
the person was taking antihypertensive medication. The FRS was
calculated using the downloadable spreadsheet calculator (http://
hp2010.nhlbihin.net/atpiii/riskcalc.htm). Age, lipids, and systolic
BP were entered as continuous variables.
The FRS is continuous score, ranging from 0 to 100%. However,
current clinical guidelines recommends categorizing asymptomatic
individuals into low (FRS < 10%), intermediate (10e20%), and high
risk subgroups (> 20%) for risk management purpose (ATP III, 2001;
Grundy et al., 2004). People in the low-risk group can be reassured
and followed with reinforcement of lifestyle changes. Intermediate-
risk group may require further risk stratification with additional
tests, whereas high-risk group are candidates for aggressive inter-
vention (Grundy et al.). In this study, we used the same cut-points to
categorize Korean women into three risk catogories.
Statistical analysis
Data were analyzed with the SPSS Complex Samples 19.0 (SPSS
Inc., Chicago, IL, USA). To account for the complex sampling design,
sampling weights were applied, and weighted means or percent-
ages were presented to describe demographics, prevalence of
cardiovascular risk factors, and the distribution of three levels of
10-year CHD risk in Korean women without CVD or diabetes. A chi-
square test was used to check for any differences in the distribution
of 10-year CHD risk by age group.
Ethical aspects
Menopausal status (n ¼ 2,716)
Having periods 66.7 (1.1)
Menopause 28.5 (1.1)
Hysterectomy 4.8 (0.5)
Menopausal age (yr; n ¼ 938) 49.1 (0.2)
Note. SE ¼ standard error.
a
Self-reported myocardial infarction, angina pectoris, stroke, or diabetes
mellitus.
especially after age 50. The prevalence of smoking was highest in
women aged 20e29 years. The rate decreased with age until 50
years and was lowest in women aged 50e59 years but after age 60,
the rate increased again with age. Obesity was most prevalent in
women aged 60e69 years. Women aged 50e59 years were the most
active; whereas women aged 70e79 years were the most sedentary.
Based on the FRS, 98.5% of asymptomatic Korean women had
a 10-year risk for CHD of less than 10%, 1.4% had 10e20% risk, and
0.1% had a risk greater than 20% (Table 3). Figure 2 presents the
prevalence of combinations of risk factors in Korean women and
the average of the FRS by age group. Overall, only about 25% of
Korean women had no risk factors, and one in three women had
two or more major risk factors for CHD. The prevalence of combi-
nation of two or more risk factors increased with age, and more
than 50% of women older than 60 years had two or more major
cardiovascular risk factors. Even for women in their 20s, approxi-
mately 1 in 2 had one or more major risk factors for CHD. The
average of the FRS increased especially after age 50.
Discussion
This study presented cardiovascular risk factors and risk clas-
sification of Korean women at three levels of CHD risk in a large

All participants provided informed consent for the KNHANES IV;

Table 2 Cardiovascular Risk Factors in Korean Women Aged 20e79 Years Without
the survey was reviewed and approved by the KCDC Institutional Cardiovascular Diseasea or Diabetes (n ¼ 2,998, Weighted n ¼ 14,420,987)
Review Board. The present study used only de-identified existing
data with no subject contact. Permission to conduct the present Cardiovascular risk factors M or % (SE)
study was granted by the University of California San Francisco Blood lipids
Committee on Human Research, and the directly downloaded SPSS Total cholesterol (mg/dL) 185.3 (0.8)
data were protected with a password. Total cholesterol  200 mg/dL 30.0 (1.0)
LDL-C (mg/dL)b 113.3 (0.7)
LDL-C  130 mg/dL 25.7 (0.9)
Results HDL-C (mg/dL) 51.4 (0.3)
HDL-C < 50 mg/dL 47.3 (1.2)
Table 1 shows the demographic characteristics of Korean Triglycerides (mg/dL) 102.9 (1.3)
Triglycerides  150 mg/dL 16.4 (0.7)
women (n ¼ 2,998; weighted n ¼ 14,420,987). The mean age was
43.7 years. About 29% of women were postmenopausal, and the Blood pressure
average menopausal age was 49.1 years. About 18% of women had Systolic blood pressure (mmHg) 110.7 (0.4)
Diastolic blood pressure (mmHg) 72.3 (0.3)
a BP  140/90 mmHg or was taking antihypertensive medications Hypertension 17.7 (0.8)
to control blood pressure (Table 2). The prevalence of smoking was Hypertension treatment 11.1 (0.7)
7.5%. Thirty percent of Korean women aged 20e79 years had total Current smoking 7.5 (0.6)
cholesterol  200 mg/dL, 25.7% had LDL-C  130 mg/dL, 47.3% had Body mass index (kg/m2) 23.0 (0.1)
Body mass index  23 kg/m2 45.9 (1.2)
HDL-C < 50 mg/dL, and 16.4% had triglyceride  150 mg/dL. About
Physical inactivityc 33.3 (1.3)
46% of women were categorized as being overweight/obese, having
a BMI  23 kg/m2. One in three was categorized as sedentary. Notes. SE ¼ standard error; LDL-C ¼ low density lipoprotein cholesterol; HDL-C ¼
high density lipoprotein cholesterol.
The mean values and the distribution of each risk factor by age a
Self-reported myocardial infarction, angina pectoris, stroke, or diabetes melli-
group were graphically depicted in Figure 1. The prevalence of tus; b Calculated result of LDL-C ¼ Total cholesterol e (HDL-C þ Triglycerides/5);
c
hypertension and dyslipidemia generally increased with age, Physical inactivity refers to women with < 600 MET-minutes/week.
4 S. Boo, E.S. Froelicher / Asian Nursing Research 6 (2012) 1e8

(%) (mm Hg) (%)

100 HTN 160 100
90 SBP 140 90 Smoking
80 DBP 80
120
70 70
60 100 60
50 80 50
40 60 40
30 30
40
20 20
10 20 10
0 0 0
20-29 30-39 40-49 50-59 60-69 70-79 20-29 30-39 40-49 50-59 60-69 70-79
Age (yr) Age (yr)
(%) (mg/dL) (%) (mg/dL)
100 220 100 140
TC ≥ 200 mg/dL
90 90
TC 200 120
80 80
70 70 100
180
60 60 LDL-C ≥ 130 mg/dL 80
50 160 50
LDL-C 60
40 40
30 140
30 40
20 120 20
20
10 10
0 100 0 0
20-29 30-39 40-49 50-59 60-69 70-79 20-29 30-39 40-49 50-59 60-69 70-79
Age (yr) Age (yr)
(%) (mg/dL) (%) (mg/dL)
100 60 100 TG ≥ 150mg/dL 160
90 90 140
50 TG
80 80
120
70 HDL-C < 50mg/dL 70
40
60 60 100
HDL-C
50 30 50 80
40 40
20 60
30 30
40
20 10 20
10 10 20
0 0 0 0
20-29 30-39 40-49 50-59 60-69 70-79 20-29 30-39 40-49 50-59 60-69 70-79
Age (yr) Age (yr)
(%) (kg/m 2) (%)
100 25 100
BMI ≥ 23 90 Physical inactivity
90 25
80 BMI 24 80
70 24 70
60 23 60
50 23 50
40 22 40
30 22 30
20 21 20
10 21 10
0 20 0
20-29 30-39 40-49 50-59 60-69 70-79 20-29 30-39 40-49 50-59 60-69 70-79
Age (yr) Age (yr)

Figure 1. Prevalence and mean values of cardiovascular risk factors in Korean women by age group (n ¼ 2,998, weighted n ¼ 14,420,987).
Notes. HTN ¼ hypertension; blood pressure 140/90 mmHg or taking antihypertensive medications; SBP ¼ systolic blood pressure; DBP ¼ diastolic blood pressure; TC ¼ total
cholesterol; HDL-C ¼ high-density lipoprotein cholesterol; LDL-C ¼ low-density lipoprotein cholesterol; TG ¼ triglycerides; BMI ¼ body mass index; physical inactivity ¼ women
with less than 600 MET-minutes/week.
 S. Boo, E.S. Froelicher / Asian Nursing Research 6 (2012) 1e8 5

Table 3 Distribution of 10-Year Riska for Coronary Heart Disease in Korean Women evidence-based guideline does not recommend estrogen replace-
Aged 20e79 Years Without Cardiovascular Diseaseb or Diabetes ment therapy for counteracting the increased risk attributable to
menopause in those without existing CHD (Mosca et al.). The best
Age (yr) n Weighted n 10-year risk 10-year risk 10-year risk p
<10% 10e20% >20% possible way to reduce the risk may be to increase the frequency of
20e29 400 2,817,678 100.0 (0.0) e e <.0001 risk factor screening during menopausal transition in order to
30e39 682 3,316,374 100.0 (0.0) e e accurately assess a woman’s CHD risk in a timely fashion. The
40e49 657 3,553,365 99.9 (0.1) 0.1 (0.1) e average age of Korean women at the time of menopause in this
50e59 525 2,456,566 100.0 (0.0) e e study was 49 years. The prevalence and combination of cardio-
60e69 445 1,382,460 96.4 (0.9) 3.4 (0.9) 0.2 (0.2)
vascular risk factors and the FRS significantly increased after the
70e79 289 894,544 81.5 (2.9) 16.8 (2.7) 1.7 (0.8)
Total 2,998 14,420,987 98.5 (0.2) 1.4 (0.2) 0.1 (0.1) age of 50. Korean women should be aware that their risk for CHD
a sharply increases after menopause. They need to be assessed
Ten-year risk was estimated with the Framingham Risk Score; b Self-reported
myocardial infarction, angina pectoris, stroke, or diabetes mellitus; Values are frequently for their cardiovascular risk during and after menopause
presented in percentages (Standard error). and should be counseled to emphasize therapeutic lifestyle
changes to prevent CHD.
randomly selected sample. The most important finding of this Another striking finding of this study is that overweight/obesity
study is that major cardiovascular risk factors are highly prevalent is highly prevalent in Korean women. In this study, 45.9% of women
in Korean women who are free of CVD or diabetes. Most risk factors aged 20e79 were overweight (21.2%) or obese (24.6%). Asians have
generally became more prevalent as one gets older, increasing the a higher percentage of body fat and more centralized fat distribu-
risk for CHD with advancing age. But this study also found that even tion compared to Caucasians of the same gender, age, and BMI so
in the younger age groups (20e39 years old), cardiovascular risk they are prone to obesity-associated diseases such as CHD or dia-
factors were already present. Smoking was much more common in betes even at a lower BMI. For this reason, the World Health
women less than 40 years old, and a high percentage of them were Organization (WHO) proposed lower BMI cut-points for over-
sedentary and overweight. The high prevalence of unhealthy life- weight (23 kg/m2  BMI < 25 kg/m2) and obesity (BMI  25 kg/m2)
styles in young women warrants increased attention because pro- for Asians (WHO, 2000). An accurate perception of normal weight is
longed unhealthy lifestyles convey substantial risk for CHD important because individuals will take actions to improve their
(Manson et al., 1999; Willett et al., 1987; Yusuf et al., 2004), and health if they are aware of the problem. Korean women need to be
maintaining a healthy lifestyle is a core aspect of CHD risk reduction informed about the culture specific cut-points for obesity, and
in women (Mosca et al., 2007). Facilitating an effective nursing future research about the gap between perceived body image and
intervention to motivate young women to be active, maintain actual BMI is warranted.
weight, and quit smoking may put a brake on the current epidemic In this study, 17.7% of Korean women had hypertension. Koreans
rise of CHD in Korea. It should be a priority to reduce the public have a higher salt intake than most other populations; it is thought
burden of CHD. that this contributes to such a high prevalence of hypertension
It is well known that menopausal transition in women (Kesteloot et al., 1980). Reducing the burden of hypertension in
contributes to increased CHD risk. Estrogen deficiency after those free of CVD is extremely important because, among the major
menopause makes existing hypertension, obesity, and dyslipidemia risk factors, hypertension contributes the most to the population-
worse or more prevalent, eventually increasing the risk for CHD attributable risk of total CVD in Koreans. It is estimated that
(Bairey Merz et al., 2003; Shaw et al., 2006). However, current about 34% of all cardiovascular events in Koreans could be

(%) FRS (%)

100 8.0
90
7.0
80
6.0
70
4 RFs
60 5.0
3 RFs
50 4.0 2 RFs
40 1 RF
3.0
30 No RF
2.0
20 Average of FRS

10 1.0

0 0.0
20-29 30-39 40-49 50-59 60-69 70-79 Total
Age (yr)
Figure 2. Prevalence of combination of cardiovascular risk factors and average of FRS in Korean women by age group (n ¼ 2,998, weighted n ¼ 14,420,987).
Notes. RF ¼ risk factor (counted risk factors; hypertension, total cholesterol  200 mg/dL, high-density lipoprotein cholesterol < 50 mg/dL, and current smoking);
FRS ¼ Framingham Risk Score.
6 S. Boo, E.S. Froelicher / Asian Nursing Research 6 (2012) 1e8
prevented by controlling high BP alone (Suh, 2001). Given the high
impact of hypertension on CVD in Koreans, important national
efforts should be made to improve early detection of hypertensive
individuals and to keep track of their medication usage. Further-
more, identification of subgroups susceptible to hypertension, and
preventing the development of hypertension among them should
be the ultimate goal.
The prevalence of current smoking in this study was 7.5%, which
is higher than the 4.8% from 2001 KNHANES data set (Ko, Kim, &
Nam, 2006). Smoking among younger women is on the rise
compared to the previous study (Ko et al.), and women 20e30 years
of age showed the highest smoking prevalence. The prevalence of
smoking decreased with age, but the rate increased again in women
after age 60. This pattern of smoking prevalence may be associated
by marital status. Previous studies conducted in Korea as well as in
Western countries have reported that people living with a partner
have lower smoking rates than people living alone (Cho, Khang, Jun,
& Kawachi, 2008; Chung, Lim, & Lee, 2010; Cox, Feng, Cañar, Ford, &
Tercyak, 2005). But in contrast to the strong beneficial effect of
marital status on men’s smoking in Western countries, in Korea,
this relationship was much stronger in women (Cho et al.; Chung
et al.). In Korea, women’s smoking has long been considered
inappropriate behavior (Chun, Doyal, Payne, Cho, & Kim, 2006).
Living with a partner may constrain Korean women from smoking.
In contrast, being single after a divorce or a loss of a partner could
liberate women from the social constraints on smoking. Such
a feeling may allow women to smoke cigarettes again. Restarting
smoking even in old age apparently makes a woman vulnerable to
CHD and significantly increases mortality from all causes of death
(Center for Disease Control [CDC], 2001). Smoking cessation may be
the most modifiable risk factor for CHD. It yields not only imme-
diate but long-term benefits for prevention of CHD (CDC).
Educating women to quit smoking as soon as possible and devel-
oping nursing interventions to prevent relapse in advanced age
appear crucial to prevent CHD in Korean women.
There is a strong association between elevated LDL-C levels and
increased risk for CHD, so the primary focus of CHD prevention
targets lowering LDL-C. In this study, 25.7% of Korean women had
LDL-C  130 mg/dL, and the rate increased with advancing age.
Although the prevalence of elevated LDL-C is relatively low
compared to the US (32% for general population age  20 years;
Rosamond et al., 2008), extra attention to LDL-C is required with
the current increases in dietary total fat intake. Furthermore,
Koreans could be at increased risk for CHD even with a smaller
amount of fat intake than Caucasians, because they have main-
tained low levels of dietary fat intake for a long time (Suh et al.,
2001). Koreans may need lower dietary fat recommendations
than other populations to prevent CHD, and culture-specific LDL-C
guidelines are required.
The most common risk factor in Korean women found in this
study was low levels of HDL-C. Compared to the US, reduced HDL-C
is highly prevalent in Korean women, and about 48% of women had
a HDL-C < 50 mg/dL. Generally HDL-C levels are higher in women
than in men before menopause. But after menopause, HDL-C drops,
and triglycerides, LDL-C, and the risk for CHD increase (Stangl,
Baumann, & Stangl, 2002). Low levels of HDL-C increase the risk
for CHD independent of total cholesterol or LDL-C, especially in
women (Gordon et al., 1989). Previous studies found that high
prevalence of reduced HDL-C in Korean women is related to
a sedentary lifestyle and excess carbohydrate intake (Kim, Kim,
Choi, & Huh, 2008; Kim, Lee, Park, & Kim, 2007). Koreans eat
unbalanced diets with high carbohydrate and low protein content.
Women over 60 years of age obtain the majority of their daily
energy intake from carbohydrates, mainly from white rice (KCDC,
2005). A prospective study showed that high carbohydrate diets
increase the risk of CHD (Liu et al., 2000). High carbohydrate diets
lead to dyslipidemia and must be viewed with concern in terms of
cardiovascular health and more tailored diet recommendations are
needed for Korean women.
Given the high prevalence of cardiovascular risk factors in Korean
women found in this study, assessing the overall effect of multiple
risk factors on the development of CHD is helpful in order to prevent
the disease. The FRS is a simple way of assessing 10-year risk for CHD.
In addition, a free web-based FRS calculator is available (http://
hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof) so women
can easily assess their own risk by themselves. This may give women
a more accurate perception and awareness of their risk and motivate
them to reduce their risk of CHD.
When using the FRS, there are two important things to keep in
mind for its appropriate use. First, the FRS is a prediction model,
thus it only can be applied to estimate 10-year CHD risk in indi-
viduals who are free of CVD. Once clinical CVD has been estab-
lished, the risk for future cardiac events is much higher than for
those without CVD. Also, the 10-year risk for development of CHD
in individuals with diabetes is so high that diabetes is considered to
be equivalent to CHD for risk-classification purposes (ATP III, 2001;
Wilson et al., 1998). Therefore, the application of the FRS to those
with already established CVD or diabetes is likely to be less useful.
Second, interpretation of the FRS requires an accurate definition of
CHD. The end point of the FRS is “hard CHD,” which includes only
myocardial infarction and coronary death, and excludes angina
pectoris (ATP III; Wilson et al.). Therefore, the interpretation of its
results is limited to the risk for myocardial infarction or coronary
death in the next 10 years.
In this study, most Korean women younger than 60 years old
had a 10-year risk that fell below 10%. However, about 20% of
women aged 70e79 years and 3.6% of women aged 60e69 had
a 10-year risk of 10% or higher. Even though they do not have
established CVD or diabetes, they are at increased risk for CHD.
Those women would benefit from additional testing or aggressive
risk factor modification therapy. Focusing on this population with
appropriate interventions would play a major role in CHD
prevention in Korea.
There are several issues that may have affected the accuracy of
the findings of this study. First, the FRS was used to estimate the 10-
year risk for CHD, given that there is no specific tool for estimating
Korean women’s risk for CHD. Although, the FRS has been most
extensively validated and adopted in the current clinical guidelines
in the US., when data are available, recalibration of the FRS should
be considered to more accurately define Korean women’s risk for
CHD. Second, the average age of Korean women in this study was
relatively young, given that the risk for CHD in women sharply
increased after menopause. Also, this study was limited to those
who completed the national survey which took 60e100 minutes
including self-administered questionnaires. Only elderly women
healthy enough might be able to participate and complete the
survey, and this could have affected our results. Third, this study
used self-reported data about diagnoses of CVD, medication use,
and smoking status thus the findings may be subject to response
bias. This may be especially true for smoking status because there is
a strong social taboo against women smoking in Korea. Participants
may respond in a socially desirable way so the risk of CHD may be
underestimated. Fourth, the prevalence of combination of risk
factors in this study was based on the number of dichotomous
major risk factors. It neither reflects which combinations of risk
factors, nor adequately account for the severity of risk factors. It is
likely that some combinations of risk factors may convey higher
risk for the development for CHD than others. Also the severity of
risk factors such as cholesterol levels or duration/amount of
smoking matters more in the development of CHD. These
 S. Boo, E.S. Froelicher / Asian Nursing Research 6 (2012) 1e8
limitations should be considered in order to appropriately interpret
the results of this study. However, the strengths of this study are
a large randomly selected sample of Korean women and therefore
the findings can be useful for defining Korean women’s risk for CHD
at the national level. These findings could be especially helpful for
public health planning and estimating costs associated with CHD
prevention. Such information may also be helpful for evaluating the
public burden of CHD over time.
Conclusion
Modifiable cardiovascular risk factors are highly prevalent in
Korean women across all age, and the combination of risk factors is
common. Korean women should be regularly assessed for their
CHD risk and should be counseled to emphasize therapeutic life-
style changes to prevent CHD. Given the multifactorial nature of
CHD, development and implementation of multifaceted nursing
interventions are required to confront the current epidemic rise of
CHD in Korean women. Furthermore, efforts to raise public
awareness about CHD in women and its risk factors are essential at
the national level as well as in all clinical settings. Korean women
should “Know their Numbers.”
Estimating 10-year risk helps to more accurately select those
needing intervention or additional testing. This study provides
estimates of the distribution of 10-year CHD risk in Korean women
at the national level. Focusing on women at increased CHD risk by
providing appropriate nursing interventions and health education
would play a major role in overall reduction in CHD. Repeated
research needs to be continued in order to evaluate the public
burden of CHD over time. Such information can hold promise for
surveillance purposes.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
The authors wish to thank Nancy Stotts, RN, EdD, Catherine
Waters, RN, PhD, and Dianne Christopherson, RN, PhD, for their
advice during manuscript preparation, Steven Paul, PhD for his
advice on statistical analysis, and Christine Hansen for her editorial
effort. We extend our appreciation to the Korea Centers for Disease
Control and Prevention in providing the data used in this study.
This study was supported by the University California at San
Francisco, Graduate Student Research Award.
References
Adult Treatment Panel III. (2001). Executive summary of the third report of the
National Cholesterol Education Program (NCEP) expert panel on detection,
evaluation, and treatment of high blood cholesterol in adults. Journal of the
American Medical Association, 285, 2486e2497.
American Diabetes Association. (2010). Diagnosis and classification of diabetes
mellitus. Diabetes Care, 33, S62eS69.
Bairey Merz, C. N., Johnson, B. D., Sharaf, B. L., Bittner, V., Berga, S. L.,
Braunstein, G. D., et al. (2003). Hypoestrogenemia of hypothalamic origin and
coronary artery disease in premenopausal women: A report from the National
Heart, Lung, and Blood Institute (NHLBI)-sponsored Women’s Ischemia
Syndrome Evaluation (WISE) study. Journal of the American College of Cardiology,
41, 413e419.
Center for Disease Control. (2001). Women and smoking: A report of the surgeon
general. Retrieved March 10, 2010, from http://www.cdc.gov/mmwr/preview/
mmwrhtml/rr5112a4.htm
Cho, H. J., Khang, Y. H., Jun, H. J., & Kawachi, I. (2008). Marital status and smoking in
Korea: The influence of gender and age. Social Science and Medicine, 66,
609e619.
Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., Jr.,
et al. (2003). Seventh report of the joint national committee on prevention,
7
detection, evaluation, and treatment of high blood pressure. Hypertension, 42,
1206e1252.
Chun, H., Doyal, L., Payne, S., Cho, S. I., & Kim, I. H. (2006). Understanding women,
health, and social change: The case of South Korea. International Journal of
Health Services, 36, 575e592.
Chung, W., Lim, S., & Lee, S. (2010). Factors influencing gender differences in
smoking and their separate contributions: Evidence from South Korea. Social
Science and Medicine, 70, 1966e1973.
Cox, L. S., Feng, S., Cañar, J., Ford, M. M. G., & Tercyak, K. P. (2005). Social and
behavioral correlates of cigarette smoking among mid-Atlantic Latino
primary care patients. Cancer Epidemiology Biomarkers and Prevention, 14,
1976e1980.
Craig, C. L., Marshall, A. L., Sjöström, M., Bauman, A. E., Booth, M. L.,
Ainsworth, B. E., et al. (2003). International physical activity questionnaire: 12-
country reliability and validity. Medicine and Science in Sports and Exercise, 35,
1381e1395.
Friedewald, W. T., Levy, R. I., & Fredrickson, D. S. (1972). Estimation of the
concentration of low-density lipoprotein cholesterol in plasma, without use of
the preparative ultracentrifuge. Clinical Chemistry, 18, 499e502.
Gordon, D. J., Probstfield, J. L., Garrison, R. J., Neaton, J. D., Castelli, W. P., Knoke, J. D.,
et al. (1989). High-density lipoprotein cholesterol and cardiovascular disease.
Four prospective American studies. Circulation, 79, 8e15.
Grundy, S. M., Cleeman, J. I., Bairey Merz, C. N., Brewer, H. B., Jr., Clark, L. T.,
Hunninghake, D. B., et al. (2004). Implications of recent clinical trials for the
National Cholesterol Education Program Adult Treatment Panel III guidelines.
Journal of the American College of Cardiology, 44, 720e732.
International Physical Activity Questionnaire. (2003). Downloadable questionnaires
and scoring protocol. Retrieved May 17, 2010, from http://www.ipaq.ki.se/ipaq.
htm
Kesteloot, H., Park, B., Lee, C., Brems-Heyns, E., Claessens, J., & Joossens, J. (1980).
A comparative study of blood pressure and sodium intake in Belgium and in
Korea. European Journal of Cardiology, 11, 169e182.
Kim, H. M., Kim, D. J., Jung, I. H., Park, C., & Park, J. (2007). Prevalence of the
metabolic syndrome among Korean adults using the new international diabetes
federation definition and the new abdominal obesity criteria for the Korean
people. Diabetes Research and Clinical Practice, 77, 99e106.
Kim, M. H., Lee, H. S., Park, H. J., & Kim, W. Y. (2007). Risk factors associated with
metabolic syndrome in Korean elderly. Annals of Nutrition and Metabolism, 51,
533e540.
Kim, W. Y., Kim, J. E., Choi, Y. J., & Huh, K. B. (2008). Nutritional risk and metabolic
syndrome in Korean type 2 diabetes mellitus. Asia Pacific Journal of Clinical
Nutrition, 17, 47e51.
Ko, M., Kim, M. T., & Nam, J. J. (2006). Assessing risk factors of coronary heart
disease and its risk prediction among Korean adults: The 2001 Korea National
Health and Nutrition Examination Survey. International Journal of Cardiology,
110, 184e190.
Korea National Statistical Office. (2010). Korean statistics. Retrieved April 10, 2011,
from http://kostat.go.kr
Korean Centers for Disease Control and Prevention. (2005). The Third Korea National
Health and Nutrition Examination Survey (KNHANES III). Retrieved October 11,
2010, from http://knhanes.cdc.go.kr/
Korean Centers for Disease Control and Prevention. (2008). The Fourth Korea
National Health and Nutrition Examination Survey (KNHANES IV-2). Retrieved
September 18, 2010, from http://knhanes.cdc.go.kr/
Lee, S. Y., Park, H. S., Kim, D. J., Han, J. H., Kim, S. M., Cho, G. J., et al. (2007).
Appropriate waist circumference cutoff points for central obesity in Korean
adults. Diabetes Research and Clinical Practice, 75, 72e80.
Liu, S., Willett, W. C., Stampfer, M. J., Hu, F. B., Franz, M., Sampson, L., et al. (2000).
A prospective study of dietary glycemic load, carbohydrate intake, and risk of
coronary heart disease in US women. American Journal of Clinical Nutrition, 71,
1455e1461.
Manson, J. E., Hu, F. B., Rich-Edwards, J. W., Colditz, G. A., Stampfer, M. J.,
Willett, W. C., et al. (1999). A prospective study of walking as compared with
vigorous exercise in the prevention of coronary heart disease in women. New
England Journal of Medicine, 341, 650e658.
Mosca, L., Banka, C. L., Benjamin, E. J., Berra, K., Bushnell, C., Dolor, R. J., et al. (2007).
Evidence-based guidelines for cardiovascular disease prevention in women:
2007 update. Circulation, 115, 1481e1501.
Rosamond, W., Flegal, K., Furie, K., Go, A., Greenlund, K., Haase, N., et al. (2008).
Heart disease and stroke statisticse2008 update: A report from the American
heart association statistics committee and stroke statistics subcommittee.
Circulation, 117(4), 25e146.
Shaw, L. J., Merz, C., Pepine, C. J., Reis, S. E., Bittner, V., Kip, K. E., et al. (2006). The
economic burden of angina in women with suspected ischemic heart disease:
Results from the national institutes of health-national heart, lung, and blood
institute-sponsored women’s ischemia syndrome evaluation. Circulation, 114,
894e904.
Smith, S. C. (2007). Multiple risk factors for cardiovascular disease and diabetes
mellitus. The American Journal of Medicine, 120, S3eS11.
Stangl, V., Baumann, G., & Stangl, K. (2002). Coronary atherogenic risk factors in
women. European Heart Journal, 23, 1738e1752.
Suh, I. (2001). Cardiovascular mortality in Korea: A country experiencing epide-
miologic transition. Acta Cardiologica, 56(2), 75e81.
Suh, I., Oh, K. W., Lee, K. H., Psaty, B. M., Nam, C. M., Kim, S. I., et al. (2001). Moderate
dietary fat consumption as a risk factor for ischemic heart disease in
8 S. Boo, E.S. Froelicher / Asian Nursing Research 6 (2012) 1e8
a population with a low fat intake: A case-control study in Korean men.
American Journal of Clinical Nutrition, 73, 722e727.
Willett, W. C., Green, A., Stampfer, M. J., Speizer, F. E., Colditz, G. A., Rosner, B., et al.
(1987). Relative and absolute excess risks of coronary heart disease among
women who smoke cigarettes. New England Journal of Medicine, 317,
1303e1309.
Wilson, P. W., D’Agostino, R. B., Levy, D., Belanger, A. M., Silbershatz, H., &
Kannel, W. B. (1998). Prediction of coronary heart disease using risk factor
categories. Circulation, 97, 1837e1847.
World Health Organization. (2000). The Asia-Pacific perspective: Redefining obesity
and its treatment. Retrieved May 17, 2010, from http://www.iotf.org/asiapacific/
Yusuf, S., Hawken, S., Ounpuu, S., Dans, T., Avezum, A., Lanas, F., et al. (2004). Effect
of potentially modifiable risk factors associated with myocardial infarction
in 52 countries (the INTERHEART study): Case-control study. Lancet, 364,
937e952.
Yusuf, S., Reddy, S., Ounpuu, S., & Anand, S. (2001). Global burden of cardiovascular
diseases. Part I: General considerations, the epidemiologic transition, risk
factors, and impact of urbanization. Circulation, 104, 2746e2753.