PLOS ONE

RESEARCH ARTICLE

Cardiovascular disease risk factors among

older people: Data from the National Health
and Morbidity Survey 2015
Shariff Ghazali Sazlina ID1,2☯*, Rajini Sooryanarayana3☯, Bee Kiau Ho4☯, Mohd.
Azahadi Omar5☯, Ambigga Devi Krishnapillai6☯, Noorlaili Mohd Tohit7☯,
Sheleaswani Inche Zainal Abidin8☯, Suthahar Ariaratnam9, Noor Ani Ahmad10☯
1 Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia,
Serdang, Selangor, Malaysia, 2 Malaysian Research Institute on Ageing (MyAgeing™), Universiti Putra
a1111111111 Malaysia, Serdang, Selangor, Malaysia, 3 Family Health Development Division, Ministry of Health Malaysia,
a1111111111 Putrajaya, Wilayah Persekutuan Putrajaya, Malaysia, 4 Klinik Kesihatan Bandar Botanik, Ministry of Health
Malaysia, Bandar Botanic, Klang, Selangor, Malaysia, 5 National Institutes of Health, Ministry of Health
a1111111111
Malaysia, Setia Alam, Shah Alam, Malaysia, 6 Department of Family Medicine, Faculty of Medicine and
a1111111111 Health, National Defense University of Malaysia, Kuala Lumpur, Malaysia, 7 Department of Family Medicine,
a1111111111 Faculty of Medicine, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia, 8 Elderly Health
Sector, Family Health Development Division, Ministry of Health, Putrajaya, Wilayah Persekutuan Putrajaya,
Malaysia, 9 Department of Psychiatry, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Selayang
Campus, Batu Caves, Selangor, Malaysia, 10 Centre for Family Health Research, Institute for Public Health,
National Institutes of Health, Ministry of Health Malaysia, Setia Alam, Shah Alam, Selangor, Malaysia
OPEN ACCESS
☯ These authors contributed equally to this work.
Citation: Sazlina SG, Sooryanarayana R, Ho BK, * [email protected]
Omar M.A, Krishnapillai AD, Mohd Tohit N, et al.
(2020) Cardiovascular disease risk factors among
older people: Data from the National Health and
Morbidity Survey 2015. PLoS ONE 15(10):
Abstract
e0240826. https://doi.org/10.1371/journal.
Study on cardiovascular disease (CVD) risk factors and their prevalence among the older
pone.0240826
people in Malaysia is limited. We aimed to determine the prevalence and factors associated
Editor: Frank T. Spradley, University of Mississippi
with CVD risk factors using the non-laboratory Framingham Generalized 10-Year CVD risk
Medical Center, UNITED STATES
score among older people in Malaysia. This was a population-based cross-sectional study
Received: July 21, 2020
using data of 3,375 participants aged �60 years from the National Health and Morbidity Sur-
Accepted: October 2, 2020 vey 2015. Sociodemographic, health factors and clinical assessments (anthropometry and
Published: October 21, 2020 blood pressure) were included. Complex survey analysis was used to obtain prevalence
Copyright: © 2020 Sazlina et al. This is an open with 95% confidence intervals (CI). We applied ordinal regression to determine the factors
access article distributed under the terms of the associated with CVD risk. The prevalence for the high 10-year CVD risk was 72.1%. Body
Creative Commons Attribution License, which mass index was higher among those aged 60–69 years in men (25.4kg/m2, 95%CI 25.1–
permits unrestricted use, distribution, and
25.8) and women (26.7kg/m2, 95%CI 26.3–27.1) than the other age groups. The factors
reproduction in any medium, provided the original
author and source are credited. associated with moderate and high 10-year CVD risk were Malay ethnicity (Odds Ratio(OR)
0.76, 95%CI 0.63–0.92, p = 0.004), unmarried status (OR 1.55, 95%CI 1.22–1.97, p<0.001)
Data Availability Statement: On the Data
Availability statement, for data protection purposes, and physically inactive (OR 0.72, 95%CI 0.55–0.95, p = 0.020). There is a need for future
the data used this study belongs to the study to evaluate preventive strategies to improve the health of older people in order to pro-
Government of Malaysia and are not publicly mote healthy ageing.
available. However, the data are available from the
Ministry of Health Malaysia upon request. A direct
contact from the Ministry imposing restrictions is:
Dr. Noor Hisham bin Abdullah (Director General of
Health, Ministry of Health Malaysia, Level 2, Block
E7, Complex E, Centre of Federal Government

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PLOS ONE CVD risk factors among elderly

Administration, 62590, Putrajaya) Tel: +603 - 8883 Introduction

2545; Email: [email protected].
Cardiovascular disease (CVD) is the leading cause of mortality globally and it is known that
Funding: Ministry of Health Malaysia, Award
CVD increases with age [1]. According to the World Health Organization (2017), 17.7 million
number: NMRR-14-1064-21877, The funders had
no role in study design, data collection and
people die annually from CVD primarily due to coronary artery disease and stroke, which
analysis, decision to publish, or preparation of the accounted for 31% of all global deaths. It is associated with tobacco use, unhealthy diet, physi-
manuscript. The authors received no specific salary cal inactivity and sedentary behaviour, which are reflected by the increased prevalence of
for this work. hypertension, diabetes, overweight and obesity. The prevalence of these non-communicable
Competing interests: The authors have declared diseases increase with age, which leads to significant mortality among older people as well as
that no competing interests exist. disability, functional decline and healthcare costs [2].
In Malaysia, the leading cause of CVD death in 2016 was coronary artery disease at 13.2%
followed by stroke at 6.9% [3]. The percentage of deaths due to CVD in the public hospitals
have increased from 15% in 2006 to 25.4% in 2010 [4]. Majority of these are among people
aged �60 years. The National Health and Morbidity Surveys (NHMS) has shown that the
prevalence of CVD risk factors such as hypertension, dyslipidemia, diabetes, overweight/obe-
sity and smoking has been on an increasing trend and it increases with age [5]. This has led to
increased demand for healthcare, especially with a high proportion of older age groups [6].
Malaysia is experiencing a demographic transition due to an increasing aged population
�60 years and increased life expectancy [7]. The longevity of the older population has raised
the requirement of health care services due to the increase in prevalence of chronic diseases
and disability. Ageing brings along an uneven increase in CVD with the related disabilities [8].
The ability of older people to remain healthy and independent requires the provision of appro-
priate health care to meet their needs.
In order to develop and implement an effective strategy for prevention and treatment of
CVD in older people, it is critical to have a more comprehensive understanding of a wide
range of CVD risk factors and the factors salient to this population. However, few studies
focused on the older people [9, 10]. Once significant CVD risk factors and their prevalence are
identified among community dwelling older people, researchers and clinicians will be able to
develop and implement effective intervention strategies to ensure healthy and productive age-
ing of the Malaysian population.
The association of biologic risk factors such as hypertension, diabetes, and dyslipidaemia
with CVD has been studied in developed countries [11, 12]. In addition to biologic risk factors,
many epidemiologic studies have demonstrated positive associations between alcohol intake,
smoking, physical inactivity, and obesity with the prevalence of CVD [13, 14]. However, these
studies focused on young to middle age groups and were from developed countries. The Fra-
mingham Generalized 10-Year CVD Risk Score (FRS) is a validated commonly used tool to
quantify the CVD risk [15]. Studies on prevalence and risk factors for CVD among older peo-
ple in Malaysia is limited. Therefore, we aimed to determine the prevalence of CVD risk fac-
tors and the associated factors of cardiovascular risk using the non-laboratory FRS among
community dwelling older people in Malaysia.

Methods
Data source
This cross-sectional study used data from the National Health and Morbidity Survey 2015
(NHMS 2015) conducted by the Institute for Public Health, National Institutes of Health and
funded by Ministry of Health, Malaysia. The Ministry of Health Medical Research Ethics Com-
mittee approved the study and the detailed description of the sampling methods are as
described in the NHMS 2015 Methodology & General Findings report [16]. Briefly, the NHMS

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PLOS ONE CVD risk factors among elderly

2015 involved Malaysian residents in non-institutionalised living quarters in both urban and
rural from all 13 states and 3 Federal Territories (FTs) in Malaysia. The Department of Statis-
tics Malaysia performed the sample selection using the sampling frame that comprised 79,240
geographical areas known as Enumeration Blocks (EB) with 7.65 million living quarters (LQs).
On average, each EB comprised 80 to 120 LQ with 500 to 600 people. A two-stage stratified
random sampling was employed for national representativeness. The states and FTs were con-
sidered as Primary Stratum, while urban and rural areas within the states were Secondary Stra-
tum. All states and FTs were included in this survey. The EBs from urban and rural areas in
each states and FTs were randomly selected. The sample selection involved two stages: 1) selec-
tion of EBs (536 EBs and 333 EBs from urban areas and rural areas, respectively), which were
considered as Primary Sampling Unit, and 2) selection of LQs within the EBs, which were con-
sidered as Secondary Sampling Unit. In each EB, a total of 12 LQs were randomly selected and
all households and individuals within the selected LQs were invited to participate in this sur-
vey. Random selection of EBs and LQs was done by the Department of Statistics Malaysia. In
the present study, data of participants aged 60 years was extracted and analysed.

Sample size
The NHMS 2015 dataset comprised 20,747 participants aged �18 years. We extracted a total
of 3,790 data of participants aged �60 years from the NHMS 2015 dataset. However, only
3,375 had complete data for the calculation of FRS and were included in the analysis of this
study.

Variables
CVD risk was the main outcome of interest in this study. The Framingham Generalised
10-Year CVD Risk Score (FRS) evaluates the actual risk of CVD and the risk estimates are age,
HDL cholesterol, total cholesterol, systolic blood pressure (BP), smoking, and diabetes [15]. In
our study, the calculation of FRS was based on the algorithm developed by D’Agostino et al.
(2008) and the risk estimates are the same for all parameters except this algorithm used non-
laboratory based methods where they substituted BMI for cholesterol [17]. Scores were
summed separately for men and women in view of the differences in risks, and the FRS were
categorised as low (10-year risk of <10%), moderate (10-year risk of 10–20%) (moderate) or
high (10-year risk of >20%) risk.
The independent variables used for analysis in this study included socio-demography,
health-related factors and clinical assessments. These variables were extracted from the NHMS
2015 dataset and the tools used to collect these data has been described in the NHMS 2015:
Methodology & General Findings report [16]. The socio-demography included age, gender,
ethnicity, marital status, location: rural or urban, highest level of education and household
monthly income. The health-related factors included in this study were known history of dia-
betes, presence of hypertension and history of treatment over the past two weeks, presence of
dyslipidemia and lifestyle information (physical activity, smoking status). The physical activity
was measured using the short version of International Physical Activity Questionnaire (IPAQ)
on walking, moderate-intensity activities, vigorous-intensity activities and sitting duration
over the last 7 days [18]. The physical activity was categorised into three categories: inactive,
minimally active and health-enhancing physical activity (HEPA).
The clinical assessments included the anthropometric measurements (BMI and waist cir-
cumference) and BP measurements. The weight was measured in kilograms (kg) using the
Tanita Personal Scale HD 319 to the nearest two decimal point and height was measured with
the SECA Stadiometer 213 in metres. The BMI was calculated based on a formula of weight (in

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PLOS ONE CVD risk factors among elderly

kg) divided by square of height (in metre). The Omron Japan Model HEM-907, which had
been validated and calibrated was used for blood pressure assessment. Waist circumference
was measured and categorised as abnormal if �80cm in women and �90cm in men [19]. All
the clinical assessments were conducted by trained nurses during the NHMS 2015 survey.

Ethical approval
This study was approved by the Medical Research Ethics Committee, Ministry of Health,
Malaysia [NMRR-14-1064-21877]. Both verbal and written consent were obtained from the
participants. Participation was voluntary. The participants were assigned non-identifiable
identification codes for data entry and data analysis. The participants would not be identified
in the report writing or publication.

Data analysis
Complex survey analysis was used to obtain prevalence and population estimates with 95%
confidence intervals. To improve the representativeness of the sample in terms of the size, dis-
tribution, and characteristics of the study population, sample weights were calculated for each
respondent prior to the analysis. The basic weight for each sampled household would be equal
to the inverse of its probability of selection (calculated by multiplying the probabilities at each
sampling stage). The basic weight was adjusted based on the non-response and post-stratifica-
tion factor to derive the sample weights.
Descriptive analysis was performed, where continuous data was presented as mean with
standard deviation considering the dataset was large and normality was assumed. Categorical
data were presented in frequency and column percentage For the purpose of analysis, three
categories of age groups were described: (i) aged 60–69 years; (ii) aged 70–79 years; and (iii)
aged 80 years and above.
Univariate analysis was carried out using Pearson’s Chi-square test, independent sample t-
test and one-way ANOVA. A Chi-square test was applied to determine the proportion of
achieving target controls for CVD risks across age groups. For the CVD risk, we applied ordi-
nal regression using the logit model to determine the factors associated with CVD risk based
on the FRS 10-year risk since the FRS risk was categories into 3 ordinal categories (i.e.: 10-year
risk of <10%, 10-year risk of 10–20% and 10-year risk of >20%) with the 10-year risk of <10%
was used as the reference group. We calculated the cumulative odds ratio from the parameter
estimates obtained from the logit model. The cumulative odds ratio (OR) with 95% confidence
interval (95%CI) and P-value were presented. We did not include age, gender, BP, BMI, smok-
ing status and history of hypertension treatment, diabetes and dyslipidemia because these were
considered in the calculation of the FRS. All analyses were carried out using SPSS version 24.0
(IBM, Armonk, NY, USA).

Results
Characteristics of participants
The mean age of the participants was 68.1 years with the majority in the age group 60–69 years
(64.7%). Majority of the participants were women (50.8%), Malay ethnicity (47.8%), with high-
est primary school education (68.0%), married (69.3%), and lived in the rural areas (28.2%).
The mean monthly household income was RM3007 (95%CI = 2748, 3267). Table 1 summa-
rises the characteristics of the study participants.
The calculated FRS showed that 72.1% had high 10-year CVD risk. The prevalence of
hypertension was 70.4%, of whom 87.4% were on antihypertension medications. The mean

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PLOS ONE CVD risk factors among elderly

Table 1. Characteristics of study participants.

Characteristics % (95%CI) Mean (95%CI)
Age (N = 3375)
• 60–69 years 64.7 (62.1–67.3)
• 70–79 years 28.1 (25.8–30.5)
• �80 years 7.2 (5.9–8.7)
Sex (N = 3375)
• Men 49.2 (47.3–51.0)
• Women 50.8 (49.0–52.7)
Ethnicity (N = 3375)
• Malay 47.8 (43.5–52.1)
• Chinese 35.1 (31.1–39.3)
• Indian 6.8 (5.4–8.6)
• Other Bumiputera 9.0 (6.7–12.1)
• Others 1.3 (0.8–1.9)
Highest level of education (N = 3348)
• No formal education 19.8 (17.6–22.3)
• Primary school 48.2 (45.5–51.0)
• Secondary school and higher 32.0 (29.3–34.7)
Marital status (N = 3375)
• Married 69.3 (66.9–71.5)
• Unmarried 30.7 (28.5–33.1)
Strata (N = 3375)
• Urban 71.8 (69.1–74.3)
• Rural 28.2 (25.7–30.9)
Monthly household income, RM (N = 3375) 3007 (2748–3267)
Presence of diabetes (N = 3375) 38.7 (36.2–41.2)
Presence of hypertension (N = 3375) 70.4 (68.3–72.5)
Presence of dyslipidaemia (N = 3375) 64.8 (62.4–67.1)
Systolic BP, mmHg (N = 3375) 143.5 (142.5–144.5)
Diastolic BP, mmHg (N = 3375) 79.2 (78.6–79.8)
On antihypertension medications (N = 823)
• Yes 87.4 (84.0–90.1)
• No 12.6 (9.9–16.0)
Smoking status (N = 3375)
• Current smoker 12.8 (11.3–14.4)
• Never smoked 82.9 (81.1–84.5)
• Former smoker 4.4 (3.5–5.4)
BMI, kg/m2 (N = 3375) 25.4 (25.2–25.6)
Waist circumference (N = 3367)
• Abnormal (Men �90cm, Women �80cm) 62.9 (60.3–65.4)
• Normal (Men <90cm, Women <80cm) 37.1 (34.6–39.7)
Physical activity (N = 3367)
• Inactive 45.2 (42.9–47.6)
• Minimally active 35.0 (32.8–37.2)
• HEPA active 19.8 (18.2–21.5)
(Continued )

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PLOS ONE CVD risk factors among elderly

Table 1. (Continued)

Characteristics % (95%CI) Mean (95%CI)

FRS (N = 3375)
• Low 10-year CVD risk 7.2 (6.1–8.5)
• Moderate 10-year CVD risk 20.7 (19.0–22.5)
• High 10-year CVD risk 72.1 (70.1–74.0)

95%CI = 95% confidence interval, SD = standard deviation, BMI = body mass index, FRS = framingham risk score,
CVD = cardiovascular disease

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systolic and diastolic blood pressure were 143.5mmHg and 79.2mmHg, respectively. About a
third had diabetes (38.7%) and two thirds had dyslipidaemia (64.8%); while majority of them
never smoked (82.9%) and had abnormal waist circumference (62.9%). The mean BMI was
25.4kg/m2 and 45.2% were inactive.
The CVD risk factors were compared between the different age groups as shown in Table 2.
The analysis separates those for men and women due to differences in risks. We found that
women had significantly higher mean systolic BP (145.2mmHg, 95%CI 143.8–146.6) and
higher proportion of dyslipidemia (73.6%, 95%CI 70.5–76.4) than men (mean systolic BP:
141.7mmHg, 95%CI 140.4–143.1; dyslipidemia: 55.7%, 95%CI 52.2–59.1). Compared to the
other age groups, the BMI was significantly higher among those aged 60–69 years in men
(25.4kg/m2, 95%CI 25.1–25.8) and women (26.7kg/m2, 95%CI 26.3–27.1). However, there
were no significant difference between the age groups on the other CVD risk factors for men
and women.
The ordinal regression (Table 3) showed that factors were associated with moderate and
high 10-year CVD risks when compared to low risk. The factors associated with these risks
were Malay ethnicity (OR 0.76, 95%CI 0.63–0.92, p = 0.004), unmarried status (OR 1.55, 95%
CI 1.22–1.97, p<0.001) and physically inactive (OR 0.72, 95%CI 0.55–0.95, p = 0.020).

Table 2. Cardiovascular disease risk factors according to age group by gender (N = 3375).
Group Presence of diabetes, % (95% Presence of dyslipidemia, % (95% Systolic BP, mmHg Mean (95% Current smoking, % (95% BMI, kg/m2 Mean (95%
CI) CI) CI) CI) CI)
Total 38.7 (36.2,41.2) 64.8 (62.4,67.1) 143.5 (142.5,144.5) 12.8 (11.3,14.4) 25.4 (25.2,25.6)
Men
Overall 36.6 (33.3,40.0) 55.7 (52.2,59.1) 141.7 (140.4,143.1) 24.7 (21.9,27.8) 24.9 (24.6,25.2)
Age
• 60–69 37.4 (33.4,41.5) 55.3 (50.9,59.6) 141.5 (140.0,143.0) 27.0 (23.6,30.8) 25.4 (25.1,25.8)
• 70–79 34.9 (29.0,41.3) 57.7 (51.1,64.0) 141.8 (139.2,144.4) 20.7 (15.9,26.5) 24.1 (23.7,24.6)
• � 80 36.0 (23.8,50.3) 50.2 (36.2,64.2) 144.0 (137.3,150.6) 18.0 (9.8,30.6) 22.1 (21.1,23.1)
Women
Overall 40.7 (37.3,44.2) 73.6 (70.5,76.4) 145.2 (143.8,146.6) 1.2 (0.7,2.0) 25.9 (25.6,26.2)
Age
• 60–69 39.9 (36.0,43.9) 75.6 (72.1,78.8) 143.5 (141.8,145.2) 0.7 (0.3,1.6) 26.7 (26.3,27.1)
• 70–79 44.5 (37.8,51.4) 69.8 (63.1,75.7) 147.6 (144.8,150.4) 1.5 (0.7,3.1) 25.1 (24.5,25.7)
• � 80 34.0 (24.4,45.0) 70.4 (59.9,79.2) 150.4 (145.4,155.4) 4.3 (1.4,12.1) 22.6 (21.6,23.5)

BP = blood pressure, BMI = body mass index

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PLOS ONE CVD risk factors among elderly

Table 3. Ordinal regression on factors associated with cardiovascular risk using non-laboratory based FRS.
Estimates (SE) Cumulative odds ratio 95% confidence interval P value
FRS
• 10-year risk of >20% 1.01 (0.220) 2.74 1.78–4.22 <0.001�
• 10-year risk of 10–20% 2.63 (0.225) 13.82 8.88–21.5 <0.001�
• 10-year risk of <10% Ref
Ethnicity
• Malay -0.23 (0.096) 0.76 0.63–0.92 0.004�
• Non-Malay Ref
Marital status
• Unmarried 0.44 (0.121) 1.55 1.22–1.97 <0.001�
• Married Ref
Highest education level
• No formal 0.03 (0.149) 1.10 0.82–1.47 9.533
• Primary -0.04 (0.120) 0.96 0.76–1.21 0.728
• Secondary or higher Ref
Monthly household income 0.15 (0.116) 1.16 0.93–1.46 0.197
Waist circumference
• Abnormal -0.06 (0.110) 0.57 0.76–1.16 0.567
• Normal Ref
Physical activity
Inactive -0.32 (0.139) 0.72 0.55–0.95 0.020�
Minimally active 0.09 (0.145) 1.09 0.82–1.45 0.534
HEPA active Ref

FRS = framingham risk score, Ref = reference group, SE = standard error,

�
p<0.05 = statistical significance
Chi-square = 4161.74; p = 0.321; Nagelkerke R2 = 0.011

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Discussion
Our study found two thirds of community dwelling older people had hypertension and dysli-
pidemia and almost half of them had diabetes. The women with hypertension in our study had
higher mean systolic BP compared to men and more women had dyslipidemia compared to
men. The mean BMI for both older men and women were in the range of overweight and were
significantly higher among those aged 60–69 years. The factors associated with moderate and
high 10-year CVD risk were Malay ethnicity, unmarried status and physically inactive, when
compared to participants with low 10-year CVD risk.
Our study found the prevalence of hypertension among the older people was comparable
with other Asian studies, which ranged between 50% and 70% [20, 21]. Our study found
women had higher levels of SBP than men, and systolic BP increases with age similar to previ-
ous studies [20, 21]. It has shown that menopause in women was associated with higher blood
pressure independent of age and BMI [22].
The prevalence of dyslipidaemia in our study population was higher at 65% when compared
to other Asian studies among older people, which ranged from 37–44% [9, 20]. In addition,
the mean BMI in our study were in the range of overweight for both men and women in those
aged less than 70 years, of whom the prevalence of dyslipidemia was the highest across the dif-
ferent age groups. Up to the age of 70 years the muscle mass decreases and the fat mass
increases [23]. Hence, this could explain the higher BMI in the age group less than 70 years.

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PLOS ONE CVD risk factors among elderly

About 40% of our study participants had diabetes. Similarly, the previous NHMS 2011
showed the prevalence of diabetes was lower in the age group of more than 75 year [24]. The
incidence of diabetes increases with age up to the age of 65 years and after the age of 65 years,
both the incidence and prevalence levels off [25].
The prevalence of current smokers among the older people has increased from 11.9% in the
NHMS 2011 to 14.8% in the present study [26]. Similar to the earlier findings, more men than
women were current smokers and the prevalence decreased with advancing age. In Malaysia,
current smokers among older people was common and most were of Malay and other Bumi-
putera ethnicities. In the present study, higher proportion of participants were of Malay eth-
nicity, which could explain the increase in the prevalence.
The Malay ethnicity was found to be associated with moderate and high 10-year CVD risk
when compared to participants with low 10-year CVD risk. We are not able to make compari-
sons with other studies as this is the first study that evaluated CVD risk among older people
that included the Malay ethnicity. However, the possible reasons could be that other ethnic
groups were found to attain better target control for the CVD risk factors such as blood pres-
sure, glucose level and cholesterol levels, when compared to Malays [27].
Our study also found that unmarried status was associated with moderate 10-year CVD
risk when compared to participants with low 10-year CVD risk. A previous study that evalu-
ated CVD risk among older people in China found that unmarried status was associated with
coronary artery disease events in men [28]. A previous review suggested that family and social
support plays an important role in the adherence of diabetes management to achieve control
[29]. It is possible that unmarried people may have less family/social support, which was not
assessed in the present study.
Unlike in previous study by Li et. al.(2011), physical inactivity was associated with higher
CVD risk among older people with T2DM in our study [10]. Also, majority of the older people
were physically inactive, of which health promotion to engage in physical activity in older age
is needed.
There were no significant associations between moderate and high 10-year CVD risk and
other factors when compared to participants with low 10-year CVD risk. FRS underestimates
CHD risk in older people, particularly in women [30]. Re-estimated risk functions using these
factors improve accurate estimation of absolute risk. The actual risk prediction with FRS
might perform less well in older people compared to middle-aged adults, and some traditional
risk factors have weaker associations with CHD risk in the elderly; for example, total and LDL-
cholesterol are strong cardiovascular risk factors in middle-aged but not in older people.
Almost three quarter of older people had a FRS high 10-year CVD risk and the prevalence
of hypertension, dyslipidaemia and diabetes are high among the community dwelling older
people in Malaysia. Initiation of treatment and individualised target control is imperative.
Controlling CVD risk factors among older people do improve outcomes with greatest atten-
tion in reducing overall CVD risks. Therefore, this study provides insight on the need for
future study to evaluate preventive strategies to improve the older people’s health in order to
promote healthy and productive ageing.

Supporting information
S1 File.
(PDF)
S2 File.
(PDF)

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PLOS ONE CVD risk factors among elderly

Acknowledgments
The authors would like to thank the Director General, Ministry of Health Malaysia for his sup-
port and permission to publish this study. We also express our gratitude to the Deputy Direc-
tor General of Health (Research and Technical Support) and Director, Institute for Public
Health for their guidance and support for this publication.

Author Contributions
Conceptualization: Shariff Ghazali Sazlina, Rajini Sooryanarayana, Mohd. Azahadi Omar,
Sheleaswani Inche Zainal Abidin, Noor Ani Ahmad.
Data curation: Shariff Ghazali Sazlina, Rajini Sooryanarayana, Mohd. Azahadi Omar.
Formal analysis: Shariff Ghazali Sazlina, Mohd. Azahadi Omar.
Funding acquisition: Rajini Sooryanarayana.
Investigation: Rajini Sooryanarayana, Mohd. Azahadi Omar, Sheleaswani Inche Zainal
Abidin.
Methodology: Shariff Ghazali Sazlina, Rajini Sooryanarayana, Bee Kiau Ho, Mohd. Azahadi
Omar, Ambigga Devi Krishnapillai, Noorlaili Mohd Tohit, Sheleaswani Inche Zainal Abi-
din, Suthahar Ariaratnam, Noor Ani Ahmad.
Project administration: Rajini Sooryanarayana, Mohd. Azahadi Omar.
Resources: Rajini Sooryanarayana, Mohd. Azahadi Omar.
Software: Rajini Sooryanarayana, Mohd. Azahadi Omar.
Supervision: Rajini Sooryanarayana, Mohd. Azahadi Omar.
Validation: Shariff Ghazali Sazlina, Rajini Sooryanarayana, Bee Kiau Ho, Mohd. Azahadi
Omar, Ambigga Devi Krishnapillai, Noorlaili Mohd Tohit, Sheleaswani Inche Zainal Abi-
din, Suthahar Ariaratnam, Noor Ani Ahmad.
Visualization: Rajini Sooryanarayana, Mohd. Azahadi Omar.
Writing – original draft: Shariff Ghazali Sazlina.
Writing – review & editing: Shariff Ghazali Sazlina, Rajini Sooryanarayana, Bee Kiau Ho,
Mohd. Azahadi Omar, Ambigga Devi Krishnapillai, Noorlaili Mohd Tohit, Sheleaswani
Inche Zainal Abidin, Suthahar Ariaratnam, Noor Ani Ahmad.

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