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Contents lists available at ScienceDirect

Primary Care Diabetes

journal homepage: http://www.elsevier.com/locate/pcd

Original research

Cardiometabolic risk factors in Venezuela. The EVESCAM study:

a national cross-sectional survey in adults
Ramfis Nieto-Martínez a,b,c,d , Juan P. González-Rivas e,b,d,∗ , Eunice Ugel d,f ,
Maritza Duran d , Eric Dávila g , Ramez Constantino h , Alberto García i , Jeffrey I. Mechanick j ,
María Inés Marulanda d
a
LifeDoc Health, Memphis, TN, USA
b
Department of Global Health and Population. Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
c
Department of Physiology, School of Medicine, University Centro-Occidental “Lisandro Alvarado” and Cardio-metabolic Unit 7, Barquisimeto, Venezuela
d
Foundation for Clinic, Public Health, and Epidemiology Research of Venezuela (FISPEVEN INC), Caracas, Venezuela
e
International Clinical Research Center (ICRC), St Anne’s University Hospital (FNUSA) Brno, Czech Republic
f
Public Health Research Unit, Department of Social and Preventive Medicine, School of Medicine, Universidad Centro-Occidental “Lisandro Alvarado”,
Barquisimeto, Venezuela
g
Department of Internal Medicine, School of Medicine “Dr. Luis Razetti”, Universidad Central de Venezuela (UCV), Caracas, Venezuela
h
Department of Internal Medicine, School of Medicine, Universidad de Carabobo, Valencia, Venezuela
i
Department of Physiology. School of Medicine “Dr. Luis Razetti”, Universidad Central de Venezuela (UCV), Caracas, Venezuela
j
The Marie-Josée and Henry R. Kravis Center for Cardiovascular Health at Mount Sinai Heart, and Division of Endocrinology, Diabetes and Bone Disease,
Icahn School of Medicine at Mount Sinai, New York, NY, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: No previous study in Venezuela and few in the Region of the Americas have reported national
Received 22 February 2020 cardiometabolic health data. Objectives: To determine the prevalence and distribution of cardiometabolic
Received in revised form 4 July 2020 risk factors (CMRF) in adults of Venezuela.
Accepted 16 July 2020
Methods: A population-based, cross-sectional, and randomized cluster sampling national study was
Available online xxx
designed to recruit 4454 adults with 20 years or older from the eight regions of the country from July
2014 to January 2017. Sociodemographic, clinical, physical activity, nutritional, and psychological ques-
Keywords:
tionnaires; anthropometrics, blood pressure, and biochemical measurements were obtained. The results
Venezuela
Risk factors
were weighted by gender, age, and regions.
Cardiovascular disease Results: Data from 3414 participants (77% of recruited), 52.2% female, mean age of 41.2 ± 15.8 years,
Tobacco were analyzed. CMRF adjusted-prevalence were: diabetes (12.3%), prediabetes (34.9%), hypertension
Dyslipidemia (34.1%), obesity (24.6%), overweight (34.4%), abdominal obesity (47.6%), underweight (4.4%), hyperc-
Diabetes holesterolemia (19.8%), hypertriglyceridemia (22.7%), low HDL-cholesterol (63.2%), high LDL-c (20.5%),
Obesity daily consumption of fruits (20.9%) and vegetables (30.0%), insufficient physical activity (35.2%), anx-
iety (14.6%) and depression (3.2%) symptoms, current smoker (11.7%), and high (≥ 20%) 10-year fatal
cardiovascular risk (14.0%). CMRF prevalence varied according to gender, age and region of residence.
Conclusions: Cardiometabolic risk factors are highly prevalent in Venezuelan adults. This situation can be
affected by the severe socio-economic crisis in the country. The joint action of different stakeholders to
implement public health strategies for the prevention and treatment of these risk factors in Venezuela is
urgently needed.
© 2020 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Cardiovascular disease (CVD) is the leading global cause of death

∗ Corresponding author at: International Clinical Research Center, St Anne’s Uni-
versity, Hospital Brno Pekarska 53, 656 91 Brno, Czech Republic.
E-mail addresses: nietoramfis@hsph.harvard.edu (R. Nieto-Martínez),
juan.gonzalez@fnusa.cz (J.P. González-Rivas).
[1]. High adiposity, hypertension, high cholesterol, and hyper-
glycemia are their most important risk factors. Between 1980 and
2010, the mortality burden of cardiometabolic risk factors (CMRF)
shifted from high-income to low and middle-income countries [2].
In Latin America, coronary heart disease and stroke cause 42.5%

https://doi.org/10.1016/j.pcd.2020.07.006
1751-9918/© 2020 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
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and 28.8% of the CVD mortality, respectively [3]. But, it is neces-
sary to identify the magnitude of the CMRF not only in each region
but in each country. Well-designed studies using sub-national sam-
ples have reported the prevalence of CMRF in Peru [4] and South
Cone (Argentina, Chile, and Uruguay) [5]. In the Americas, only 14
of 37 countries have reported national studies, and most of them
are based on self-reported data.
Venezuela is a middle-income country privileged on geographic
localization, oil resources, and climate, but immersed in a politi-
cal turmoil, hyperinflation, and socio-economic changes that can
influence the prevalence of non-communicable (NCD), especially
cardiometabolic and nutritional diseases. Previous data in diabetes
and CMRF in Venezuela has come from communities [6], a city
[7], a state [8], and a sub-national study in three regions [9–13],
or from the calculation of weighted prevalence from available
studies [14]. Therefore, the objective of the Venezuelan Study of
Cardiometabolic Health (EVESCAM, for the acronym in Spanish)
is to determine the prevalence of cardio-metabolic risk factors in
adults in a national sample of Venezuela.
2. Methods
2.1. Study design
The study design, sampling, and implementation were
described previously [15,16]. In brief, the EVESCAM was a
population-based, observational, cross-sectional, and cluster sam-
pling study, designed to evaluate cardiometabolic risk factors
among subjects aged ≥ 20 years in Venezuela from July 2014 to
January 2017.
2.2. Population
The Bolivarian Republic of Venezuela consists of 23 states, a
capital district, federal entities, and 335 municipalities distributed
in 8 regions (Capital, Central, Western, Northeast, Guayana,
Andeans, Zulia, and The Llanos). The population size reported by
the Venezuelan National Institute of Statistics (www.ine.gov.ve;
accessed on January 21, 2018) was 31,431,164 inhabitants in 2017,
of whom 65.3% were 20 years or older and 50% were female.
2.3. Sampling and recruitment
A multi-stage stratified sampling method was used to select
a representative sample of the general population of Venezuela.
4454 women and men, aged 20 years and older, were recruited
from randomly selected samples in the eight regions of Venezuela.
Initially, 23 cities (1st stage) from the eight regions – one to four
cities per region – were chosen. Each selected city was stratified
by municipalities. Two municipalities (2nd stage) in each city, then
two parishes (3rd stage) in each municipality, and finally two loca-
tions (4th stage) in each parish, were randomly selected. In the 5th
stage, mappings and censuses of each location delimited the streets
or blocks (primary sampling units) and selected the households to
visit. Actual household visits were conducted in the 6th stage. The
visits to households started from number 1 onwards skipping every
two houses. That is, the household visited were 1, 4, 7, 10, 13, 16
and so on. If the number of people required after covering all house-
holds of this sequence was not achieved, the sampling continued
on households 2, 5, 8, 11, and so on, until obtaining the number of
subjects required to complete the sample from that sector.
In each household, all members were eligible to enter the study
and were invited to participate if met the criteria. Inclusion criteria
were all those subjects with 20 or older years of age living in the
house selected for more than six months. Exclusion criteria were
current pregnancy, inability to stand or communicate, or refusal to
Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
participate in the study by not signing the informed consent. Then,
identification data and a social status questionnaire were collected
from each subject in their home. Finally, subjects were invited to
assist to the physical and metabolic evaluation in a nearby health
center and an instructive that includes a detailed explanation of
the evaluation procedures was provided and explained. The evalu-
ations were carried out in a total of 47 community health centers
throughout the country.
The main objective of the EVESCAM was to determine the preva-
lence cardiometabolic risk factors and diseases in Venezuela. The
target sample size was calculated in 2940 participants based on a
previous report on diabetes (prevalence 7.7%, standard deviation
1.55%, and confidence level 95%) [6]. Therefore, considering a mini-
mal expected response rate of 70%, the final target sample size was
increased to 4200, representing the proportions of the country in
terms of age, sex, and proportion of rural and urban populations. In
each region, at least 525 subjects were recruited. The sampling also
considered that is necessary to evaluate at least 70% of recruited
subjects in each region. Thus, if after recruiting 525 subjects the
evaluation of at least 70% has not been achieved, the recruitment
was to continue until that response rate was reached in each region.
For this study, 4454 subjects were recruited (86.3% urban and 13.7%
rural areas), of which 3414 were evaluated, corresponding to a net
response rate of 76.7%.
The study protocol complied with the Helsinki declaration and
approved by the National Bioethics Committee (CENABI). Consent
from all participants was obtained and filed. The present report is
presented according to the Strengthening the Reporting of Obser-
vational Studies in Epidemiology (STROBE) [17].
2.4. Clinical and biochemical measures
A customized questionnaire was used to collect information
on demographics, family and personal history, including type 2
diabetes (T2D) and CV risk, socioeconomic status (SES) [18], use
of health care facilities, tobacco history, and depression and/or
anxiety symptoms [19]. Dietary intake was ascertained using
both a food frequency questionnaire adapted to the Venezuelan
population. Questionnaires, anthropometrics, and other physical
measurements were obtained by trained and certified health per-
sonnel. Blood pressure was measured twice, with five minutes
intervals, in the right arm, supported at heart level, in a sitting
position, after five minutes of rest, with a validated oscillometric
sphygmomanometer (Omron HEM-705C Pint® Omron Healthcare
CO., Kyoto/Japan) [20]. Weight was measured with the lightest
possible clothes, without shoes, using a calibrated scale (Tanita UM-
081® , Japan). Height was measured using a portable stadiometer
(Seca 206® Seca GmbH & Co., Hamburg, Germany). Body mass index
(BMI = kg/m2 ) was calculated for all subjects. Waist circumference
was measured twice with a measuring tape, at the iliac crest, in a
horizontal plane with the floor, at the end of expiration, and the
average of both was used.
Blood specimens were collected according to a standardized
protocol after at least 8-h of fasting. Samples were centrifuged,
frozen, and shipped to the central laboratory to be stored at −40◦
until assay. Blood tests included total cholesterol, triglycerides, and
HDL-c; LDL-c was calculated applying the Friedewald’s formula.
Fasting blood glucose and a 2-h oral glucose tolerance test (OGTT)
using a 300 ml test solution containing 75 g anhydrous glucose was
performed.
2.5. Definitions
A questionnaire validated in the Venezuelan population and
based on four variables (source of income, profession of house-
holder, educational level, and housing conditions), was used to
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determine SES [18]. A Likert-type scale ranging from 4 to 20 points

rated each item from 1 to 5, being 1 the best situation and 5 the
worst. Thus, the population was categorized by four strata: SES I —
high class (4–6 points); SES II — middle-high class (7–9 points); SES
III — middle class (10–12 points); SES IV — relative poverty (working
class, 13–16 points); and SES V — extreme poverty (marginal class,
17–20 points). Education was categorized as: (a) illiterate, subjects
with no reading or writing skills; (b) primary education, those who
attended or finished primary school; (c) secondary education, those
who attended or finished high school; and (d) higher education,
those who attended or finished university including techniques.
Diabetes was established if fasting plasma glucose was ≥ 126
mg/dL or 2-h after 75 g oral glucose tolerance test ≥ 200 mg/dL
or personal history of diabetes [21]. Prediabetes was established
if fasting plasma glucose ≥ 100 mg/dL and <126 mg/dL or glucose
level after a 75 g oral glucose tolerance test ≥ 140 mg/dL and ≤ 199
mg/dL [21]. Hypertension was defined as systolic blood pressure ≥ Fig. 1. Final sample for analysis to estimate the prevalence of cardiometabolic risk
140 mmHg or diastolic blood pressure ≥ 90 mmHg, or self-report factors.
of hypertension or antihypertensive medication use [22]. BMI was
categorized as underweight < 18.5 kg/m2 , normal weight 18.5–24.9
were obtained from the Venezuelan 2011 census. All continu-
kg/m2 , overweight 25–29.9 kg/m2 , and obesity ≥ 30 kg/m2 [23].
ous variables were initially tested for normality (Q–Q plots). All
Abdominal obesity was defined as a waist circumference ≥ 94 cm in
variables had normal distribution and were presented as mean ±
men or ≥ 90 cm in women [24]. Dyslipidemia was defined according
standard deviation (SD), except the metabolic equivalents (METs),
to the American Association of Clinical Endocrinologist and Ameri-
with skewed distribution, which was presented as median and
can College of Endocrinology (AACE/ACE) 2017 [25] cut-off values:
interquartile range (IR). Differences between parametric variables
hypercholesterolemia (≥200 mg/dL of total cholesterol); high Low
were assessed by the Student t-test or analysis of variance (ANOVA).
Density Lipoprotein cholesterol (LDL-c ≥ 130 mg/dL) low High
Differences between nonparametric variables (e.g., METs) were
Density Lipoprotein cholesterol (HDL-c < 40 mg/dL HDL-c); and
assessed by the Mann–Whitney U test Proportions were pre-
hypertriglyceridemia (≥150 mg/dL of triglycerides) or prescription
sented as prevalence and 95% confidence intervals (95% CI) and
of lipid lowering medications.
compared using the Chi-square test. A p-value < 0.05 was con-
Physical activity was assessed using the International Question-
sidered significant. Crude results are presented in Supplementary
naire of Physical Activity (IPAQ) short version which evaluates the
Appendix.
frequency of physical activity and time spent in the last 7 days in
vigorous, moderate activity, walking and seated [26]. Subjects were
categorized as “minimally active” if they participated in: (a) 3 or 3. Results
more days of vigorous activity of at least 20 min per day, or (b) 5 or
more days of moderate-intensity activity or (c) walking of at least 3.1. Subjects characteristics
30 min per day, or (d) 5 or more days of any combination of walking,
moderate- or vigorous intensity activities achieving a minimum of Out of 3445 subjects who completed all stages of data collection,
at least 600 MET-min/week. Subjects were categorized as “inactive” 31 did not complete the evaluation. The final sample comprised
if they did not reach any of the above criteria [26]. Current smoker 3414 participants (Fig. 1).
was defined as those individuals who report using more than 100
cigarettes, 20 tobaccos, or 20 pipes throughout his life, and reported
3.1.1. Sociodemographic
using it in the past twelve months. Daily consumption of fruits
Fifty-two percent of the study subjects were female. Almost 48%
and/or vegetables was reported. Anxiety and depression symptoms
of the population was categorized as poor; only 21.2% were consid-
were determined using the Hospital Anxiety and Depression Scale
ered high and middle-upper class (Table 1). Eight out 10 subjects
(HADS), a self-report questionnaire with 14 items (7 for depres-
were mixed race and lived in urban locations. Only 3.3% of the
sion and 7 for anxiety), with each item completed on a Likert scale
population was illiterate, 39.1% not completed high school, 31.6%
from 0 to 3 points, which categorizes subjects as normal (<8 points),
had technique education or high school and 25.9% had a univer-
mild symptoms (8–10 points), or moderate/severe symptoms (≥11
sity degree. When a health service was required, 67.4% attended
points), in each of the two domains [19]. A laboratory-based risk
to public health care centers (53.2% the traditional hospital and
score (Globorisk) derived from a prediction model that includes
ambulatory network and 14.2% the “Barrio Adentro” parallel Cuban
age, sex, smoking, blood pressure, diabetes, and total cholesterol
mission network) and 21% used private centers (almost 12.5% with
was used to estimate the 10-year risk of fatal and non-fatal car-
insurance coverage and 8.5% out of pocket).
diovascular disease [27]. As is suggested for low-middle income
countries, a score ≥ 20% was considered high risk [27].
3.1.2. Anthropometric and cardiometabolic risk factors
2.6. Data analysis The mean age was 41.2 ± 15.8 years (Table 2). It is noteworthy
that the mean of some CMRF (BMI, fasting blood glucose, HDL-
All calculations were performed using SPSS 20 software (IBM cholesterol in both genders, and waist circumference in women)
corp. Released 2011; Armonk, NY, USA). Data were weighted to were outside the normal range. Men presented higher age, weight,
address any imbalance in the distribution of variables in the sam- height, values of metabolic syndrome components (higher blood
ple compared with the whole Venezuelan population. Sampling pressure, fasting blood glucose, triglycerides, and lower HDL-c), and
weights were created using standardized population weights for 10-year high fatal and non-fatal CVD risk score than women (p <
gender in combination with a second set of weights based on the 0.01); instead women presented higher 2h-post 75 g blood glucose,
region and age distribution in Venezuela. Population distributions total cholesterol, and LDL-c and less METS than men (p < 0.01).

Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
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Table 1
Sociodemographic characteristics.

Total Men Women P

n (%) 3414 (100.0) 1631 (47.8) 1783 (52.2)

Socioeconomic Status (%) % 95% CI % 95% CI % 95% CI

I — high 2.5 1.8 – 3.4 1.5 1.0 - 2.2 2.0 1.5 – 2.5 0.843
II — middle upper class 19.8 17.9 – 21.8 18.7 16.9 – 20.5 19.2 17.9 -20.6 0.871
III — middle class 31.0 29.5−32.6 30.8 28.2−33.0 31.3 29.1−33.4 0.76
IV — relative poverty 42.1 40.5−43.8 40.6 38.2−43.1 43.5 41.2−45.8 0.08
V — extreme poverty 5.7 4.8−6.4 6.3 5.1−7.5 5.1 4.0−6.1 0.13

Ethnicity % 95% CI % 95% CI % 95% CI

Mixed 78.4 77.0−79.8 76.7 74.6−78.7 80.0 78.1−81.8 0.02
Hispanic White 14.8 13.6−16.0 16.1 14.3−18.8 13.6 12.0−15.1 0.05
Afro-Venezuelan 5.5 4.7−6.3 5.7 4.6−6.8 5.4 4.3−6.4 0.68
Amerindian 1.3 0.9−1.7 1.5 0.9−2.1 1.1 0.6−1.5 0.22

Location % 95% CI % 95% CI % 95% CI

Urban 80.8 79.3−82.0 82.4 80.5−84.2 79.1 77.2−80.9 0.01
Rural 19.4 18.1−20.1 17.6 15.8−19.5 20.9 19.0−22.8 0.01

Education % 95% CI % 95% CI % 95% CI

Illiterate 2.0 1.4–2.7 2.0 1.4–2.7 2.0 1.6–2.5 0.90
Primary 17.0 15.2–18.8 16.1 14.4–17.8 16.5 15.3–17.8 0.73
Secondary 45.0 42.4–47.2 39.8 37.6–42.1 42.3 40.7–44.0 0.03
University or more 36.0 33.5–38.1 42.1 39.8–44.4 39.2 37.6–40.8 0.01

Health services % 95% CI % 95% CI % 95% CI

Public hospital or ambulatory 53.2 51.6−55.0 51.2 48.8−53.6 55.1 52.7−57.3 0.02
¨Barrio AdentroN̈etwork 14.2 13.0−15.3 14.0 12.3−15.7 14.3 12.7−15.9 0.82
Private centers out of pocket 8.5 7.6−9.4 8.9 7.5−10.3 8.1 6.9−9.4 0.39
Private centers with insurance 12.5 11.4−13.6 15.0 13.2−17.6 10.3 8.8−11.6 0.001
Both public and private 9.0 8.0−10.0 7.8 6.5−9.1 10.0 8.6−11.3 0.02

Proportions are presented as percent (95% CI). Chi-square test was used to determine differences between categorical variables.

Table 2
Anthropometric and cardiometabolic risk factors by gender.

Total Men Women p

Age (years) 41.2 ± 15.8 41.9 ± 16.5 40.5 ± 15.1 0.007

Weight (kg) 72.5 ± 17.9 77.7 ± 17.7 67.7 ± 16.7 0.001
Height (m) 1.64 ± 0.09 1.70 ± 0.07 1.58 ± 0.06 0.001
Body mass index (kg/m2 ) 26.8 ± 5.9 26.7 ± 5.4 27.0 ± 6.3 0.092
Waist circumference (cm) 91.6 ± 14.1 92.9 ± 14.0 90.5 ± 514.1 0,001
Systolic blood pressure (mmHg) 126.7 ± 20.7 130.6 ± 19.4 123.1 ± 21.3 0.001
Diastolic blood pressure (mmHg) 75.2 ± 11.6 75.8 ± 11.7 74.7 ± 11.4 0.007
Fasting blood glucose (mg/dL) 102.2 ± 30.2 105.3 ± 33.7 99.3 ± 26.3 0.001
2h-post 75 g blood glucose (mg/dL) 112.3 ± 36.1 110.8 ± 38.2 113.6 ± 34.1 0.034
Total cholesterol (mg/dL) 155.5 ± 39.8 153.8 ± 39.4 156.9 ± 40.1 0.020
Triglycerides (mg/dL) 108.4 ± 64.4 116.6 ± 72.7 100.8 ± 54.6 0.001
LDL-c (mg/dL) 96.8 ± 31.0 95.8 ± 30.9 97.7 ± 31.1 0.070
HDL-c (mg/dL) 36.9 ± 11.2 34.9 ± 10.5 38.7 ± 11.2 0.001
METS (min/week) 1597 (495−4788) 2014 (669−5939) 1356(396−3810) 0.001
Personal cardiovascular heart disease (%) 1.4 (1.1−1.9) 1.3 (0.8−2.0) 1.6 (1.1−2.3) 0.501
Family history of stroke (%) 32.9 (31.4−34.5) 32.4 (30.2−34.7) 33.4 (31.2−35.6) 0.533
Family history of premature CVD (%) 19.4 (18.1−20.7) 18.0 (16.1−19.8) 20.8 (18.9−22.7) 0.033
10-year high fatal CVD risk score 10.3 ± 9.3 12.4 ± 9.6 8.3 ± 7.3 0.001

Continues variables are presented as mean ± standard deviation of the mean. Except METS which is presented as median and IQR. Proportions are presented as percent
(95% CI). Student t-test and Chi-square test were used to determine differences between continues and categorical variables respectively. (p < 0.01) Abbreviations: CVD —
Cardiovascular diseases; HDL-c — High density lipoprotein cholesterols; LDL-c — Low density lipoprotein cholesterol.

3.2. Prevalence of cardiometabolic risk factors 3.2.1. By gender

The most prevalent CMRF in Venezuela were non-daily con-
sumption of fruits (79.1%) and vegetables (70.0%), low HDL-c
(63.2%), and abdominal obesity (47.6%) (Table 3). Hypertension,
overweight, prediabetes, and physical inactivity affected around
35% of the population, almost 25% was affected by obesity, 12.3% by
diabetes, and 4.4% by underweight. Other dyslipidemias (hyperc-
holesterolemia, hypertriglyceridemia, and high LDL-c) ranged from
19.8% to 22.7%. (Table 3). Approximately, 12% were current smok-
ers and 14.6% and 3.2% reported anxiety and depression symptoms,
respectively. According to the Globorisk score, 14% of the popula-
tion had a 10-year high risk of a fatal or non-fatal cardiovascular
event.
Diabetes, hypertension, overweight, hypertriglyceridemia, low
HDL-c, current smokers, non-daily intake both fruits and vegeta-
bles, and 10-year high CVD risk were more prevalent in men than
women (p < 0.05). Underweight, obesity, anxiety and depression
symptoms, and physical inactivity were more prevalent in women
than men (p < 0.05) (Table 3).
3.2.2. By age and gender
Most of CMRF were affected by age, but their distribution was
heterogeneous (Table 4). Traditional risk factors, such as diabetes,
hypertension, abdominal obesity, hypercholesterolemia, hyper-
triglyceridemia, high LDL-c, and physical inactivity increased with
age in both genders. Hypertension and 10-year high CVD risk

Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
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Table 3
Prevalence of cardiometabolic risk factors by gender.

Total Men Women p

Diabetes 12.3 (11.2−13.4) 14.5 (12.7−16.2) 10.3 (8.9−11.7) 0.001

Prediabetes 34.9 33.3−36.5 36.9 34.5−39.2 33.1 30.9−35.3 0.023
Hypertension 34.1 (32.5−36.6) 36.4 (34.0−38.7) 32.0 (29.8−34.1) 0.007
Underweight 4.4 (3.7−5.1) 3.6 (2.7−4.5) 5.1 (4.1−6.1) 0.016
Normal weight 36.6 (35.0−38.2) 36.2 (33.9−38.6) 36.9 (34.7−39.2) 0.686
Overweight 34.4 (32.8−36.0) 38.0 (35.9−40.3) 31.2 (29.0−33.3) 0.001
Obesity 24.6 (23.1−26.0) 22.2 (20.2−24.2) 26.7 (24.7−28.8) 0.002
Abdominal obesity 47.6 45.9−49.3 46.7 44.3−49.1 48.5 46.1−50.8 0.302
Hypercholesterolemia 19.8 (18.5−21.1) 17.9 (11.6−19.8) 21.4 (19.6−23.4) 0.001
Hypertriglyceridemia 22.7 (21.3−24.1) 24.6 (22.6−26.8) 20.9 (19.0−22.8) 0.001
Low HDL-c 63.2 (61.5−64.8) 70.9 (68.7−72.1) 56.0 (45.1−66.5) 0.001
High LDL-c 20.5 (19.2−21.9) 18.9 (17.0−21.9) 22.0 (20.1−24.0) 0.020
Anxiety symptoms 14.6 (13.4−15.8) 9.6 (8.1−11.1) 19.2 17.4−21.1 0.001
Depression symptoms 3.2 (2.5−3.7) 2.1 (1.4−2.8) 4.1 3.1−5.0 0.001
Daily fruits intake 20.9 (19.5−22.3) 19.1 (17.2−21.0) 22.6 (20.8−24.6) 0.016
Daily vegetables intake 30.0 (28.5−31.5) 28.2 (26.0−30.4) 31.7 (29.5−33.8) 0.023
Physical inactivity 35.2 (33.5−36.9) 29.9 (27.5−32.2) 39.9 (37.5−42.2) 0.001
Current smoker 11.7 (10.6−12.7) 17.0 (15.1−18.8) 6.8 (5.6−8.0) 0.001
10-year high fatal CVD riska 14.0 (12.4−15.9) 19.2 (16.5−22.3) 9.1 (7.2−11.3) 0.001

Data are percent and (95% CI). Chi-square test was used to determine differences by gender.
a
Calculated by Globorisk.

Table 4
Prevalence of cardiometabolic risk factors by age and gender.

20–34 years 35–49 years 50−64 years 65 and more years p

Men
Diabetes 3.5 (2.3−5.2) 16.7 (13.8−20.2) 26.5 (21.7−32.0) 26.7 (20.9−33.3) 0.001
Prediabetes 35.1 31.5−38.9 36.5 32.5−40.7 39.4 33.8−42.5 40.5 33.8−47.2 0.433
Hypertension 13.9 (11.4−16.8) 36.1 (33.1−40.3) 59.5 (53.6−65.1) 76.8 (70.4−82.2) 0.001
Underweight 4.5 (3.1−6.4) 4.0 (2.6−6.1) 1.4 (0.6−3.6) 2.6 (1.1−5.9) 0.011
Normal weight 45.9 (42.0−49.8) 22.5 (19.1−26.3) 32.7 (27.5−38.4) 46.9 (40.0−53.9) 0.001
Overweight 31.2 (27.7−34.9) 42.7 (38.6−47.0) 46.8 (41.0−53.6) 34.4 (28.0−41.4) 0.001
Obesity 18.5 (15.6−21.7) 30.7 (26.9−34.8) 19.1 (14.9−24.1) 16.1 (11.6−22.0) 0.001
Abdominal obesity 33.3 29.8−37.1 53.6 49.3−57.8 59.1 53.3−64.7 53.6 46.6−60.5 0.001
Hypercholesterolemia 9.7 (7.6−12.2) 18.1 (15.0−21.6) 28.4 (23.4−33.9) 29.2 (23.3−35.9) 0.0001
Hypertriglyceridemia 17.5 (14.7−20.6) 26.2 (22.6−30.1) 35.4 (30.0−41.1) 28.2 (22.4−34.9) 0.0001
Low HDL-c 71.0 (67.4−77.4) 73.0 (69.1−76.6) 71.8 (66.3−77.8) 63.9 (56.9−70.3) 0.119
High LDL-c 11.1 (8.8−13.8) 20.0 (16.8−23.7) 28.6 (23.5−34.3) 27.2 (21.4−33.9) 0.0001
Anxiety symptoms 9.2 7.1−11.7 8.0 5.9−10.7 13.2 9.6−17.7 8.7 5.4−13.6 0.357
Depression symptoms 0.5 0.1−1.4 2.3 1.3−4.0 4.2 2.3−7.3 4.4 2.2−8.4 0.001
Daily fruits intake 16.9 (14.2−20.0) 21.0 (17.7−24.6) 15.5 (11.7−20.3) 25.7 (20.0−32.3) 0.010
Daily vegetables intake 28.1 (24.7−31.7) 27.8 (24.2−31.8) 28.7 (23.7−34.2) 28.6 (22.7−35.4) 0.990
Physical inactivity 23.1 (20.0−26.8) 29.6 (25.6−33.8) 34.5 (28.9−40.6) 45.6 (38.5−52.8) 0.000
Current smoker 17.1 (14.3−20.2) 19.0 (15.9−22.5) 16.2 (21.3−21.0) 11.8 (8.0−17.1) 0.140
10-year high fatal CVD risk – – 3.9 (2.3−6.6) 22.7 (18.1−27.9) 53.8 (44.8−62.5) 0.000

Women
Diabetes 3.9 (2.7−5.6) 9.4 (7.3−12.0) 17.5 (13.8−22.0) 30.7 (23.7−38.8) <0.001
Prediabetes 22.1 19.3−25.3 38.7 34.8−42.7 44.0 37.8−49.4 42.9 35.0−51.0 <0.001
Hypertension 11.7 (9.6−14.2) 31.1 (27.5−35.0) 58.2 (52.7−63.4) 82.1 (75.0−87.6) <0.001
Underweight 8.6 (6.8−10.8) 2.4 (1.5−4.0) 1.9 (0.8−4.0) 5.1 (2.5−10.1) <0.001
Normal weight 46.8 (43.3−50.4) 30.8 (27.2−34.7) 27.2 (22.7−32.2) 31.4 (24.2−39.6) <0.001
Overweight 23.6 (20.6−26.7) 36.1 (32.2−40.0) 35.9 (30.8−41.2) 40.9 (33.0−49.2) <0.001
Obesity 21.0 (18.2−24.0) 30.7 (27.0−34.5) 35.0 (30.0−40.0) 22.6 (16.4−30.3) <0.001
Abdominal obesity 33.7 30.4−37.1 55.0 50.8−59.0 64.9 59.6−69.1 62.4 54.2−70.0 <0.001
Hypercholesterolemia 7.6 (5.9−9.7) 19.3 (16.2−27.2) 43.2 (38.2−49.8) 51.4 (43.2−56.5) <0.001
Hypertriglyceridemia 8.4 (6.6−10.6) 20.5 (17.4−24.0) 38.6 (33.4−44.0) 47.1 (33.4−43.9) <0.001
Low HDL-c 57.7 (54.1−61.6) 60.3 (56.2−64.2) 49.1 (43.7−54.5) 45.7 (37.7−54.0) 0.001
High LDL-c 7.8 (6.0−9.9) 21.0 (17.8−24.5) 44.1 (38.7−49.5) 50.4 (42.1−58.5) <0.001
Anxiety symptoms 20.9 18.0−24.0 18.4 15.4−21.8 18.5 14.6−23.1 15.6 10.4−22.6 0.382
Depression symptoms 2.5 1.6−4.0 4.5 3.0−6.5 5.4 3.4−8.5 6.7 4.0−12.0 0.097
Daily fruits intake 20.5 (17.7−26.3) 20.2 (17.1−23.6) 29.1 (24.4−34.3) 28.4 (21.6−36.3) 0.002
Daily vegetables intake 27.3 (24.9−30.6) 33.5 (29.8−37.5) 38.1 (32.9−43.5) 32.6 (25.4−40.7) 0.001
Physical inactivity 36.5 (33.0−40.2) 40.8 (36.7−45.0) 38.9 (33.5−44.5) 56.5 (47.9−64.8) <0.001
Current smoker 4.0 (2.8−5.7) 7.1 (5.3−9.5) 12.6 (9.4−16.6) 7.8 (4.4−13.4) <0.001
10-year high fatal CVD risk – – 1.4 (0.6−3.3) 9.3 (6.6−12.9) 37.8 (28.5−48.1) <0.001

Data are percent and (95% CI). Chi-square test was used to determine differences.

in both genders and diabetes in women were the only condi- vegetable intake, and current smoker) and in women (anxiety
tions that increase in each age category with no overlap between and depression symptoms) were present in the youngest (20–34
confidence intervals. Some unfavorable risk conditions in men (pre- years) individuals in a similar proportion to its older counter-
diabetes, underweight, low-HDL-c, anxiety symptoms, non-daily parts.

Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
 Table 5
Prevalence by sex of cardiometabolic risk factors by regions.

PCD-925; No. of Pages 9

G Model
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national

Andeans (n = 418) Capital (n = 416) Central 14(n = 467) Guayana (n = 445) North-Eastern (n = 409) The Llanos (n = 436) Western (n = 425) Zulia (n = 404)

Diabetes M† 10.9 (7.0−16.6) 16.8 (12.9−21.7) 14.1 (10.3−18.8) 8.2 (4.2−15.3) 15.5 (11.4−20.6) 10.1 (6.5−15.1) 17.9 (13.1−23.9) 16.7 (12.4−22.2)
F 7.7 (4.6−12.8) 10.6 (7.8−14.4) 13.8 (10.4−18.1) 10.5 (5.6−18.7) 10.3 (6.9−15.1) 5.5 (3.1−9.6) 11.4 (8.0−16.0) 10.2 (6.9−14.7)
Total† 9.3 (6.6−12.9) 13.5 (11.0−16.4) 13.9 (11.3−17.0) 9.7 (6.2−14.5) 13.0 (10.2−16.4) 7.7 (5.5−10.8) 14.3 (11.3−17.8) 13.2 (10.4−16.6)
Prediabetes M 21.2 (15.6−28.1) 31.5 (26.4−37.1) 44.5(38.6−50.6) 39.8 (30.7−49.7) 22.2 (26.5−38.2) 30.2 (24.1−37.0) 42.6 (35.8−49.7) 50.7 (44.1−57.2)
F 14.3 (9.8−20.4) 33.7 (28.8−39.0) 37.8 (32.5−43.4) 31.4 (22.6−41.8) 34.1 (28.1−40.7) 23.0 (17.7−29.3) 36.7 (30.9−42.5) 44.1 (37.9−50.4)
Total† 17.7 (14.0−22.2) 32.7 (29.0−36.5) 40.9 (36.9−45.0) 35.7 (29.1−42.8) 33.1 (28.9−37.6) 26.5 (22.3−31.1) 39.3 (34.8−43.9) 47.5 (42.9−52.0)
Hypertension M 39.4 (32.2−47.0) 41.2 (35.6−47.1) 35.2 (29.6−41.2) 37.8 (28.8−47.6) 38.6 (32.6−45.0) 27.0 (21.2−33.7) 31.7 (25.5−38.7) 37.7 (31.6−44.3)
F 22.0 (16.4−28.9) 33.7 (28.8−39.0) 36.8 (31.6−41.4) 37.5 (28.1−47.9) 36.0 (29.8−42.6) 28.5 (22.7−35.1) 28.6 (23.3−34.5) 31.4 (25.8−37.5)
Total 30.8 (26.1−36.0) 37.2 (33.4−41.1) 36.1 (32.2−40.1) 37.8 (31.2−45.0) 37.2 (32.8−41.8) 27.8 (26.3−36.5) 29.9 (25.7−34.3) 34.6 (30.4−39.1)
Underweight M† 0.6 (0.1−3.4) 2.9 (1.5−5.6) 0.8 (1.5−5.6) 5.3 (2.3−11.7) 9.4 (6.3−13.9) 5.3 (2.9−9.5) 1.6 (0.5−4.6) 3.2 (1.5−6.4)
F† 4.2 (2.1−8.4) 2.1 (1.0−4.4) 3.6 (2.0−6.4) 9.2 (4.7−17.1) 7.5 (4.7−11.8) 10.1 (6.6−15.0) 2.9 (1.4−5.8) 6.4 (3.9−10.3)
Total† 2.4 (1.2−4.7) 2.6 (1.6−4.2) 2.3 (1.4−3.9) 7.1 (4.2−11.2) 8.5 (6.3−11.5) 7.7 (5.5−10.8) 2.1 (1.1−3.9) 5.0 (3.4−7.5)
Normal weight M† 39.832.5−47.5) 20.5 (16.2−25.6) 26.2 (16.2−25.6) 56.8 (46.8−66.3) 40.8 (34.7−47.2) 55.9 (48.7−62.7) 32.3 (26.0−39.2) 38.6 (32.4−45.2)
F† 41.3 (34.1−48.9) 38.7 (33.5−44.0) 31.1 (26.2−36.6) 43.7 (33.7−54.1) 37.6 (31.3−41.2) 46.7 (40.0−53.3) 32.7 (27.1−38.7) 31.9 (26.3−38.1)
Total† 40.7 (35.6−46.2) 30.2 (26.7−34.0) 28.9 (25.3−32.8) 50.3 (43.1−57.4) 39.2 (34.8−43.8) 51.0 (46.1−56.0) 32.6 (28.3−37.1) 35.1 (30.8−39.6)
Overweight M† 43.5 (36.1−51.2) 49.3 (43.5−55.1) 43.4 (43.5−55.1) 23.2 (15.8−32.6) 37.3 (31.9−43.7) 26.1 (20.3−32.7) 37.0 (30.5−44.1) 31.8 (26.0−38.2)

R. Nieto-Martínez et al. / Primary Care Diabetes xxx (2020) xxx–xxx

F† 31.1 (24.6−38.5) 29.1 (24.5−34.3) 34.1 (29.0−39.6) 28.7 (20.3−39.0) 35.7 (29.5−42.3) 22.1 (16.9−28.4) 35.5 (29.8−41.7) 30.2 (24.7−36.4)

ARTICLE IN PRESS
Total† 37.1 (32.0−42.4) 38.4 (34.6−42.3) 38.2 (4.3−42.3) 26.2 (20.4−33.0) 36.5 (32.2−41.1) 24.0 (20.0−28.5) 36.0 (31.6−40.6) 30.9 (26.8−35.3)
Obesity M† 16.1 (11.3−22.6) 27.3 (22.4−32.8) 29.7 (22.4−32.8) 14.7 (9.0−23.2) 12.4(8.8−17.3) 12.8 (8.7−18.3) 29.1 (23.1−35.9) 26.4 (8.2−16.7)
F† 23.4 (17.6−30.3) 30.1 (25.3−35.2) 31.1 (26.2−36.5) 18.4 (11.6–27.8) 19.2 (14.5−25.1) 21.1 (16.0−27.3) 29.0 (23.6−34.9) 31.5 (25.9−37.7)
Total† 19.8 (15.8−24.4) 28.7 (25.2−35.4) 30.5 (26.8−34.5) 16.4 (11.7−22.4) 15.7 (12.6−19.4) 17.3 (13.8−21.3) 29.3 (25.2−33.8) 28.9 (25.0−33.3)
Abdominal obesity M† 45.2 (37.8−57.8) 62.0 (56.2−67.5) 60.3 (54.2−66.1) 25.3 (17.7−34.6) 34.8 (28.9−41.1) 31.9 (25.7−38.9) 50.0 (42.9−57.0) 44.8 (38.4−51.4)
F† 53.0 (45.4−60.4) 54.1 (48.7−59.4) 51.6 (46.0−57.2) 28.7 (20.3−39.0) 46.5 (40.0−53.2) 35.0 (28.7−41.8) 56.3 (50.1−62.4) 54.9 (39.0−51.5)
Total† 49.1 (43.8−54.4) 55.5 (53.9−61.7) 55.5 (51.4−59.6) 26.9 (21.0−33.7) 40.3 (35.8−44.8) 33.7 (29.2−38.5) 53.6 (48.8−58.2) 45.0 (40.4−49.5)
Hypercholesterolemia M† 26.5(20.4−33.7) 19.4 (15.2−24.4) 14.9 (11.5−19.8) 12.2 (7.5−20.2) 20.5 (15.8−26.1) 13.8 (9.6−19.4) 18.9 (14.0−25.1) 15.4 (11.2−20.8)
F† 34.5 (27.7−42.0) 20.1 (16.2−24.9) 17.6 (13.6−22.3) 19.5 (12.6−29.1) 24.3 (19.0−30.5) 18.0 (13.3−23.9) 18.0 (13.3−23.9) 22.0 (17.1−27.7)
Total 30.5 (25.8−36.4) 19.7 (16.7−23.1) 16.3 (13.5−19.6) 16.1 (11.5−22.1) 22.4 (18.7−22.5) 16.0 (12.7−20.0) 18.9 (15.5−22.8) 19.0 (15.6−22.9)
Hypertriglyceridemia M† 41.0 (33.7−48.6) 18.3 (14.2−23.2) 30.7 (25.4−36.6) 17.3 (11.1−26.0) 17.2 (12.9−22.5) 19.1 (14.2−25.4) 32.3 (26.0−39.2) 22.6 (17.5−28.7)
F† 36.3 (29.4−43.8) 15.2 (11.7−19.5) 21.9 (17.6−26.9) 20.5 (13.3−30.0) 17.3 (12.8−22.9) 14.0 (9.9−19.5) 23.6 (18.7−29.3) 22.9 (18.0−28.8)
Total 38.4 (33.7−43.7) 16.6 (13.8−18.9) 26.0 (22.5−29.8) 18.8 (13.8−25.0) 17.2 (14.0−21.0) 16.5 (13.1−20.5) 27.4 (22.4−31.7) 22.8 (13.8−25.0)
Low HDL-c M 72.9 (65.7−79.1) 83.9 (79.1−87.7) 94.9 (91.4−96.9) 58.2 (48.3−67.4) 46.4 (40.1−52.7) 52.7 (45.5−59.7) 78.4 (72.0−83.7) 66.5 (60.0−72.5)
F 47.9 (40.5−55.4) 64.7 (59.4−69.7) 81.4 (76.6−85.4) 43.2 (33.3−53.6) 33.6 (27.6−40.2) 38.5 (32.0−45.4) 75.5 (69.8−80.5) 37.3 (31.4−43.7)
Total 60.1 (54.8−65.3) 73.7 (70.0−77.0) 87.6 (84.6−90.0) 50.8 (43.6−57.9) 40.3 (35.8−44.8) 45.2 (40.4−50.2) 76.8 (72.6−80.5) 51.3 (46.7−55.9)
High LDL-c 22.4 (16.6−29.6) 23.4 (18.8−28.7) 16.4 (12.3−21.5) 14.3 (8.7−22.6) 16.7 (12.4−22.1) 13.9 (9.7−19.6) 30.1 (24.0−37.0) 11.9 (8.2−17.0)
F 28.5 (22.1−35.8) 21.6 (17.5−26.3) 21.4 (17.1−26.4) 20.7 (13.5−30.3) 23.8 (18.6−30.0) 17.8 (13.1−23.7) 23.4 (18.5−29.1) 19.9 (15.3−25.5)
Total† 25.5 (21.1−30.6) 22.4 (19.3−25.9) 19.2 (16.1−26.7) 17.3 (12.5−23.4) 20.2 (16.7−24.2) 15.9 (12.6−19.9) 26.2 (22.3−30.7) 16.1 (12.9−18.9)
Anxiety symptoms M 11.7 (7.6−17.5) 13.3 (9.5−18.3) 9.2 (6.2−13.5) 9.1 (4.5−17.6) 10.0 (6.8−14.6) 5.3 (2.9−9.5) 8.5 (5.3−13.3) 8.1(5.2−12.5)
F† 16.4 (11.5−22.8) 24.4 (20.0−29.6) 21.2 (16.9−26.3) 16.9 (10.1−26.8) 13.9 (10.0−19.3) 16.0 (11.6−21.7) 18.4 (14.1−23.8) 21.2 (16.5−26.8)
Total† 14.3 (10.9−18.5) 19.5 (16.4−23.1) 15.7 (12.8−18.9) 12.9 (8.5−19.1) 11.9 (9.2−15.3) 10.8 (8.1−14.3) 14.1 (11.1−17.7) 14.9 (11.9−18.5)
Depression symptoms M† 3.1 (1.3−7.0) 2.3 (1.0−5.2) 2.8 (1.3−5.6) 1.3 (0.2−6.9) 1.8 (0.7−4.5) 1.1 (0.3−3.8) 3.7 (1.8−7.5) 0.9 (0.3−3.)
F† 6.1 (3.3−10.8) 5.1 (3.1−8.3) 4.7 (2.8−7.8) 2.6 (0.7−8.9) 1.9 (0.8−4.8) 3.5 (1.7−7.1) 4.2 (2.3−7.5) 3.4 (1.7−6.5)
Total† 4.6 (2.8−7.4) 3.8 (2.7−6.1) 3.8 (2.5−5.8) 1.9 (0.6−5.5) 1.8 (0.9−3.6) 2.3 (1.2−4.3) 4.0 (2.5−6.2) 2.2 (1.2−4.0)
Fruits M† 25.8 (19.7−33.0) 24.7 (20.0−30.0) 14.5 (10.7−19.3) 21.5 (14.6.38.0) 20.7 (15.9−26.4) 20.7 (15.6−27.1) 11.6 (7.8−17.0) 14.9 (20.0−30.1)
F† 25.9 (19.8−33.1) 30.5 (25.8−35.8) 16.0 (12.2−20.6) 19.5 (12.6−29.1) 19.9 (15.1−25.8) 26.0 (20.4−32.5) 23.4 (18.5−29.1) 17.4 (13.1−22.7)
Total† 20.3 (21.4−30.8) 28.0 (24.6−31.7) 15.2 (12.5−18.5) 20.8 (15.5−27.2) 20.3 (16.8−24.3) 23.5 (19.5−27.2) 18.0 (14.6−21.) 16.2 (13.1−19.8)
Vegetables M† 33.1 (26.4−40.7) 30.9 (25.7−36.6) 27.0 (22.0−32.7) 21.9 (14.8−31.1) 20.2 (15.5−25.8) 23.9 (18.4−30.5) 24.3 (18.8−30.9) 40.3 (34.0−46.8)
F† 42.5 (35.3−50.1) 38.1 (33.0−43.5) 27.5 (22.7−32.8) 20.7 (13.5−30.4) 23.7 (18.5−29.9) 20.5 (15.5−26.6) 27.5 (22.2−33.4) 46.4 (40.1−52.7)
Total† 37.9 (33.8−43.2) 35.0 (31.3−38.8) 27.2 (16.6−44.4) 21.3 (16.0−27.8) 21.8 (18.2−25.9) 21.9 (18.1−26.3) 26.0 (22.1−30.4) 43.4 (38.9−48.0)
Physical inactivity M† 44.8 (36.6−52.2) 40.3 (34.4−46.6) 32.4 (26.7−38.8) 22.7 (15.2−32.5) 18.0 (13.4−23.7) 21.7 (16.2−28.4) 36.0 (29.3−43.2) 22.2 (17.1−28.4)
F† 55.9 (48.0−63.6) 37.7 (32.5−43.3) 44.2 (38.4−50.1) 44.0 (33.9−54.7) 27.0 (21.3−33.5) 39.3 (32.4−46.6) 45.8 (39.5−52.1) 31.0 (25.3−37.3)
Total† 50.7 (44.9−56.4) 38.8 (34.8−42.9) 39.0 (34.7−43.3) 33.3 (26.7−40.7) 22. 6(18.8−26.8) 30.6 (26.0−35.6) 41.6 (37.0−46.5) 26.8 (22.8−31.1)
Current smoker M* 21.1 (15.6−27.9) 15.8 (11.9−25.0) 18.8 (14.4−23.9) 17.2 (11.0−25.8) 18.0 (13.6−23.5) 17.5 (12.7−23.5) 15.3 (10.8−21.1) 13.6 (9.7−18.8)
F 5.4 (2.8−9.9) 10.0 (7.2−13.7) 6.9 (4.6−10.4) 5.7 (2.5−12.8) 6.1 (3.6−10.1) 6.5 (3.8−10.8) 5.7 (3.4−9.3) 6.8 (4.2−10.7)
Total† 13.1 (9.9−17.2) 12.5 (10.1−15.4) 12.3 (9.8−15.3) 11.8 (7.9−17.3) 12.3 (9.6−15.7) 11.8 (8.9−15.4) 9.7 (7.2−12.8) 10.1 (7.6−13.2)
10-year high M† fatal 17.1 (10.3−27.1) 14.1 (9.4−20.6) 25.7 (18.4−34.6) 14.3 (6.7−27.8) 22.6 (15.9−31.0) 13.0 (7.0−23.0) 16.7 (10.0−26.5) 27.2 (19.1−37.0)
CVD riskF† 8.3 (3.9−17.0) 7.6 (4.3−13.2) 10.2 (6.0−16.6) 9.8 (3.9−22.5) 9.0 (4.8−16.2) 9.2 (4.5−17.8) 8.7 (4.7−15.8) 11.2(6.4−19.0)
Total† 12.9 (8.4−19.3) 10.6 (7.6−14.7) 17.3 (13.0−22.6) 12.0 (6.7−20.8) 16.3 (11.9−21.8) 11.0 (6.9−17.2) 12.2 (8.2−17.2) 18.9 (14.0−25.1)

Data are percent and (95% CI). Chi-square test was used to determine differences between regions. †p < 0.01; *p < 0.05.
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In men, diabetes increased until the 50th decade, whereas
hypercholesterolemia, hypertriglyceridemia, and high LDL-
c increased until that age in women. In women, low HDL-c
decreased after the 50th decade. In men, some CMRF were similar
in all age categories but lowest before the 50th decade (hyper-
cholesterolemia, hypertriglyceridemia, high LDL-c, and physical
inactivity). Nutritional status and current smokers also varied with
age. Current smoker was less prevalent in the oldest group in men
and in the youngest group in women. In men, the prevalence of
underweight was lower at the groups with 50–64 years (1.4%) and
65 or more years (2.6%) compared with younger ages (∼4.3%) (p <
0.01), and prevalence of obesity was higher at the35–49 years old
group. In women, the prevalence of underweight was very high at
the30–34 years old group (8.6%), followed by the 65 years or older
group (5.1%) (p < 0.01) (Table 4).
3.2.3. By regions
Prevalence of CMRF varied among regions (Table 5). This het-
erogeneity goes from the Andes region with 5 of the worst values
of CMRF, highest dyslipidemia, hypercholesterolemia (30.5%) and
hypertriglyceridemia (38.4%), physical inactivity (50.7%), current
smoker (13.1%) and depressive symptoms (4.6%) to Los Llanos
region with the least adverse cardiometabolic profile. The preva-
lence of diabetes in the Llanos (7.7%) was half that observed in the
Western region (14.3%), and the prevalence of obesity (17.3%) was
nearly half that observed in the Central region (30.5%) (p < 0.01).
Although the highest prevalence (43.4%) of daily consumption of
vegetables (p < 0.01) and the second lowest proportion of high LDL-
c (16.1%) was found, Zulia region showed the highest composite
10-year high CVD risk (18.9%) compared with the lowest one in
the Capital region (10.6%) and almost half of the population (47.5%)
in Zulia was in a prediabetic state which is more than double the
lowest prediabetes proportion in the country found in the Andeans
region (17.7%).
Western region also showed a high number of CMRF elevated
(diabetes, obesity, low HDL-c, high LDL-c, low consumption of
fruits, and higher physical inactivity), but also the lowest preva-
lence of current smokers compared with other regions. Central
region presented the highest prevalence of low HDL-c (87.6%) and
the lowest prevalence of hypercholesterolemia (16.3%). Capital
region presented the highest prevalence of daily consumption of
fruits (28.0%). North-Eastern region presented the highest preva-
lence of underweight (8.5%) and the lowest prevalence of obesity
(15.7%).
4. Discussion
Cardio-metabolic diseases are a global problem and information
on their distribution and determinants in low- and middle-income
countries is needed. The EVESCAM is contributing relevant data
regarding the prevalence and distribution of cardiometabolic dis-
ease and its risk factors. This is the first report presenting the
prevalence of CMRF from a nationally representative evaluation of
adults in Venezuela. The sample was obtained randomly from the
eight regions and then a weighted analysis was made to obtain rep-
resentative data of the whole country. The population was mostly
mixed race and from urban areas (∼80%), with a high proportion
of poverty (47.8%), high educational degree, a 64.9% had completed
high school and 27.7% had reached university degree. Most of the
population is attended in public health care centers (67.4% in pub-
lic centers exclusively, and 9% in both public and private centers).
CMRF prevalence varied by gender, age, and region evaluated.
In the EVESCAM, the diabetes prevalence (12.3%) was very high
compared with previous reports. The Cardiovascular Risk Factor
Multiple Evaluation in Latin America (CARMELA) study (2008) was
the first to obtain data representative (n = 1848) of the prevalence
Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
7
of cardiovascular risk factors in a city of Venezuela. Prevalence
of diabetes was 6% in Barquisimeto [7]. The CARMELA also stud-
ied 6 other capitals of Latin America (n = 11,550) with a global
prevalence of 7% [7]. In Maracaibo (2007–2009), the second large
city of Venezuela, prevalence of diabetes of 8.8% was obtained
in 2026 subjects evaluated [28]. During 2006–2010, 1392 adults
were evaluated in three regions of the country in the Venezuelan
Metabolic Syndrome, Obesity, and Lifestyle Study (VEMSOLS), age-
standardized prevalence of diabetes was 8.0% [12], consistent with
a weighted prevalence of eight studies in the country of 7.0% from
2006 to 2010 [14]. This represents around a 75% increase in dia-
betes prevalence in Venezuela in less than a decade. Our results in
diabetes prevalence are similar to those obtained in 7524 subjects
from 3 subnational samples from Argentina, Uruguay, and Chile
(12.4%) in the Centro de Excelencia en Salud Cardiovascular para
el Cono Sur (CESCAS) I study (2010–2011) [5] and higher than that
obtained in the baseline data of 3238 adults studied in 4 settings of
Peru (7%) [4] in the Cohort Study CRONICAS (2010–2011). World-
wide, diabetes prevalence is continually growing, the number of
subjects with diabetes increased from 108 million in 1980 (4.5%) to
422 million in 2014% (8.4%) [29]. This increase is primarily based
on a longer life expectancy and the obesity epidemic [29].
A striking finding of our study is the high prevalence of pre-
diabetes (34.9%), which was similar in all age categories. In the
EVESCAM, an OGTT was performed to all participants which let us
detect a higher proportion of the population at risk to develop dia-
betes and the prediabetes subtypes (impaired fasting glucose and
impaired glucose tolerance). The heterogeneous distribution across
the regions ranged from 17.7% in Andeans region to 47.5% in Zulia
region imposes the challenge of determining the geospatial compo-
nents and determinants of these differences, and thus implement
more effective prevention strategies. This number represent about
7 million adults with prediabetes, potentially 2 million of new cases
with T2D in the next three to five years. This high prevalence was
similar than the observed in the US in 2017 (33.9%) [30].
Hypertension prevalence in our study (34.1%) was also higher
than reported previous reports in Barquisimeto (CARMELA, 24.7%)
[7], Maracaibo (23.1%) [28], the three regions evaluated in the
VEMSOLS (31.3%) [13], and Peru (19.7%) [4] but lower than South-
ern Cone countries (40.8%) [5]. Worldwide, high blood pressure
(≥140/90 mmHg) prevalence is getting lower in high and middle-
income countries but is continually growing in low-income and
in some middle-income countries [31]. High and middle-income
countries are more exposed to advances in prevention and treat-
ment that could account, in part, for these blood pressure trends
[32]. However, blood pressure is also influenced by genetic, nutri-
tional, behavioral, emotional, and social drivers that are difficult to
determine once specific interventions are already in place [33–35].
Contrary to the observed with diabetes and hypertension, obe-
sity prevalence (24.6%) in this study was lower than previously
reported within Venezuela, Maracaibo (33.8%) [28] and VEMSOLS
(29.3%) [36], and also in the Region, Peru (26.9%) [4] and South-
ern Cone (35.7%) [5]. Conversely, underweight prevalence changed
from 1.1% in VEMSOLS [36] to 4.4% in this report. These changes
suggest a population weight reduction trend, contrary to the world-
wide tendency where the number of subjects with obesity has
increased from 105 million (4.8%) in 1975 to 641 million (12.8%) in
2014 [37]. The current Venezuelan sociopolitical crisis which gen-
erates a large inflation rate (over 1 million), shortage of foods and
transportation deficit could explain, in part, these results by mod-
ification of the energy balance. The pathological distribution of fat
has decreased but in a lower proportion. The percentage of subjects
with abdominal obesity in our study (47.6%, cutoff ≥ 94 cm in men
and ≥ 90 cm in women) was higher to data obtained 20 years ago in
Zulia state (42.9%, cutoff ≥ 120 cm in men and ≥ 88 cm in women)
but using a lower cutoff and lower than obtained in Maracaibo 10
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8 R. Nieto-Martínez et al. / Primary Care Diabetes xxx (2020) xxx–xxx
years ago (50.7%) [28] with a similar cutoff. In CESCAS (Argentina,
Uruguay, and Chile) a higher prevalence of abdominal obesity was
reported (52.9%) [5].
Such as obesity, dyslipidemias prevalence, except low HDL-
c, were also lower than previous reports. Comparing VEMSOLS
and the EVESCAM, the change is represented as follow: hyper-
triglyceridemia (39.7% and 22.7%); hypercholesterolemia (22.2%
and 19.8%); high LDL-c (23.3% and 20.5%); low HDL-c (58.6% and
63.2%), respectively [9]. These differences are present despite the
cut-off values to define dyslipidemias in EVESCAM were lower than
those used in VEMSOLS, which was based on the Adult Treatment
Panel (ATP) III [38] and the use of lipid lowering drugs was not con-
sidered in the VEMSOLS to define dyslipidemia. Higher values of
triglycerides (32.3%) and low HDL-c (65.3%) also were reported in
a study made between 1999 and 2001 that represented the popu-
lation of the Zulia State of Venezuela [8]. A change in Venezuelan’s
nutritional habits could drive these differences, but this analysis is
beyond the scope of this paper.
Several cardiometabolic risk behaviors were evaluated in the
EVESCAM. The prevalence of physical inactivity was significant
(35.2%) and higher in women (∼ 40%) than men (∼ 30%). The pro-
portion of physical inactivity in our report is higher than reported
worldwide (31.1%) [39] in adults, lower than reported in the Amer-
icas (43%) [39] and similar than reported in Southern Cone (35.2%)
[5]. Daily consumption of fruits and vegetables has been estab-
lished as a cardioprotective behavior [40]. Few previous studies
have reported fruits and vegetable intake in Venezuela. A study
using food frequency questionnaire informed twice more intake of
fruits (40% vs. 20.9%) and a half intake of vegetables (14% vs. 30%)
in adult women compared with this study [41].
Tobacco smoking in Venezuela was previously assessed in Bar-
quisimeto city as part of the CARMELA study. The prevalence of
current smokers was 21.8%, 32.2% in men and 14.9% in women [7],
duplicating the observed in this report, 11.7% total, 17.0% in men
and 6.8% in women. These values were also lower than reported
in Maracaibo (14.9%, 2007–2009) [28]. This is in concordance with
the global tendency. Worldwide, the age-standardized prevalence
of daily smoking was 25.0% in men and 5.4% in women, represent-
ing 28.4% and 34.4% reductions, respectively, since 1990 [42]. In
Venezuela, this is probably resulting from the strong tobacco con-
trol policies implemented and the continuous increasing cost of
tobacco due to the rising inflation rate. This study is the first on
using Globorisk score to report of 10-year fatal and non-fatal CVD
risk in Venezuela. 14% of the population, twice in men (19.2%) than
women (9.1%) had more than 20% risk of CVD. These results are
higher than Mexico (7.5% in men and 6.9% in women) and Jamaica
(8.0% in men and 6.9% in women) [27].
The impact of the current sociopolitical crisis on the CMRF
prevalence limits the interpretation of this study. All the regions
were not assessed during the same year; in consequence, some
regions were more exposed to the crisis than others. This situa-
tion of complex humanitarian emergency causes food insecurity
and is probably related to obesity reduction and can be driving
the improvement of some CMRF. However, other CMRF’s could
be worsening like the increasing the prevalence of underweight
which is related to undernutrition and increased risk for com-
municable diseases. Despite this limitation, the study has many
strengths, including the national representativeness, the multi-
stage stratified sampling, the standardization of the data collection
and laboratory process including OGTT in all participants, and the
weighing analysis, ensuring the result’s external validation.
5. Conclusion
The first national study in Venezuela reporting the prevalence
and distribution of CMRF in adults is presented. An evident hetero-
Please cite this article in press as: R. Nieto-Martínez, et al., Cardiometabolic risk factors in Venezuela. The EVESCAM study: a national
cross-sectional survey in adults, Prim. Care Diab. (2020), https://doi.org/10.1016/j.pcd.2020.07.006
geneity in the profile of CMRF is described. Notoriously, compared
with previous reports, some risk factors were highest (diabetes,
hypertension and underweight), similar (Low HDL-c) and lowest
(obesity, abdominal obesity, dyslipidemia, and current smoker).
An alarming number of subjects with prediabetes, as well as, low
intake of vegetables and fruits and high physical inactivity, are an
urgent call to implement structured lifestyle plans to prevent dia-
betes and cardiovascular disease and reduce their negative burden
on mortality and costs of healthcare systems. Considering the cur-
rent complex humanitarian emergency context in Venezuela with a
shortage of medications, electric service, gasoline, food insecurity,
and hyperinflation, allostatic overload as a measure of popula-
tion stress can worsen the outcomes. From a resource-constrained
setting perspective, these findings will serve for purposes of estab-
lishing priority in vulnerable groups and regions to overcome the
crisis and appropriately implement interventions to tackle the bur-
den of cardiometabolic diseases.
Authors contributions
RNM and MIM conceived the idea of this study. RNM conceived
and designed the overall study with support from EU, JPGR, MD and
MIM. RNM and JPGR contributed with data analysis and wrote the
draft of the manuscript. EU and JPGR made the statistical analysis.
MIM, EU, MD, JPGR, ED, RC, AG and RNM coordinated and super-
vised fieldwork activities and recollected data. MIM, EU, MD and
JM contributed to the discussion and review.
Funding
The EVESCAM was partially funded by a grant of Novartisand
donations.
Conflicts of interest
JM has received honoraria from Abbott Nutrition International
for lectures and program development. The other authors declare
no conflict of interest.
Acknowledgments
We thank the Venezuelan Society of Internal Medicine directive
and members and the EVESCAM research team for their continued
collaboration and support.
Appendix A. Supplementary data
Supplementary material related to this article can be found,
in the online version, at doi:https://doi.org/10.1016/j.pcd.2020.07.
006.
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