2024

Faculty of Arts
and Sciences

Department of
Nutrition and Food
Sciences

[POST-TRAUMATIC DISORDER AND CARDIOVASCULAR

DISEASE IN LEBANESE ELDERLY AGED 65 AND ABOVE]
Prepared by Rasha Hijazi

Presented To Doctor Nicole Sayegh

Research Proposal

2023-2024

A Quantitative Cohort Post-traumatic Disorder and Cardiovascular Disease

in Lebanese Elderly Study

Table of Contents

1.Introduction ..........................................................................................................
2.Literature Review ................................................................................................
3.Objectives and Hypothesis ...............................................................................
4.Methodology ....................................................................................................... 4
A. Study Design
B. Sample Size
C. Method of Sampling

Tools and Instruments ...............................................................................................

Dependent Variable
Independent Variable
 Inclusion Criteria

D . Statistical Analysis
E. Expected Outcomes
References .............................................................................................................
Appendix

Title

A Quantitative Cohort Post-Traumatic Disorder and Cardiovascular Disease

in Lebanese Elderly Study

Abstract

Lebanon has been facing food insecurity and an economic crisis for the past few
years, especially after the Beirut Blast. This proposal aims to study post-traumatic
stress disorder in elderly and the associated risk factors mainly cardiovascular
outcomes and the confounding role of socioeconomic situation in Lebanon, using
The PTSD Checklist-Specific Version and taking North Lebanon elderly region
and randomly selecting participants to increase representation. Scientific data
shows that post-traumatic stress is a significant risk factor for PTSD. Research
suggests that there is a strong correlation between the onset and course of
cardiovascular disease (CVD) and post-traumatic stress disorder (PTSD). The sum
of previous theories explains the link between PTSD and cardiovascular

disease and view PTSD as a stress-related mental illness that causes behavioral,
psychological, and physiological reactions that act as catalysts for the
development of cardiovascular diseases. Research findings show that post-
traumatic diagnostic criteria represent only the "tip of the iceberg" in terms of a
larger systemic condition containing components that are risk factors for
cardiovascular disease. Thus, these systemic physiological and behavioral factors
should be considered as intrinsic parts of PTSD that have a direct impact on the
development of CVD. The conceptualization of PTSD as a cardiovascular risk
factor needs further research. It is suggested that treatments that aim to reduce
cardiovascular disease risk need to address both the PTSD diagnostic components
and its associated cardiovascular risk factors. In addition, decreasing post-
traumatic stress disorder can lead to primary prevention of cardiovascular disease
which can lead to cost-benefit on the whole north region community and increase
quality adjusted life year, if the treatment was effective, Further, research is
needed to test the applicability and implications of the systemic disorder
perspective.

Keywords PTSD- Cardiovascular Disease- Lebanon- Elderly- Socioeconomic

factor

Background

A mental Disorder known as PTSD can lead to many physical risk factors that can
increase the prevalence of the disease and highly disrupt the heath burden of a
country. Lebanon is not in a place to face more health conflicts, it is essential to
understand the underlying factors of PTSD and search for innovative techniques to
treat the disease before it prevail through the population.

Introduction

Even with the innovation of science, psychiatric disorders remain complex and
their effect is still unclear, previous research found that post-traumatic stress
disorder is related to heart disease and pre-mature death (1)Post-traumatic stress
disorder and cardiovascular disease are two different yet interrelated health
conditions that have gained significant attention in recent years due to their diverse
relationship. (1).Cardiovascular disease is one of the leading cause of mortality
worldwide, it is extremely important to analyze the causes and risk factors and
learn new prevention methods to decrease the rate of death.(1)Post-traumatic stress
disorder is a mental health disorder that occurs in individuals who experienced
traumatic events. It is characterized by symptoms such as intrusive thoughts,
flashbacks, emotional numbness, and sleep apnea (2).Psychological stress might be
caused by anxiety, depression, and traumatic events, Stress is the reaction
connecting an individual with his environment. (2) Psychological stress can lead to
physical health consequences such as inflammation, increase of blood pressure,
weight gain , insulin resistance, Myocardial Infarction, and Ischemic Stroke .(2)

Literature review

Previous scientific evidence shows that post-traumatic stress disorder (PTSD) is a

primary risk factor for the diagnosis and prognosis of cardiovascular disease
(CVD).(3) Most scientific analysis forms the idea that PTSD leads to
physiological, behavioral, and psychological responses that might be causal factors
in the development of cardiovascular disorders. (3) Furthermore in order to treat
cardiovascular disease PTSD diagnostic components should be tested. According
to the American Psychiatric Association PTSD is defined as having the following
symptoms persistent for at least a month sleep apnea, avoidance of traumatic
situation, mood and personality alterations. PTSD is a heterogeneous disorder
since it has several determinants. (3) In addition PTSD can also lead to
physiological changes and therefore can be considered as a systematic disorder that
might affect the Central Nervous System, and Peripheral Nervous System(3)
Stroke is the third cause of mortality and morbidity worldwide, on the other hand
psychological disorder is slightly analyzed and rarely considered to be studied.(4)
The World Health Organization stated that 70 percent of adults suffer from one
traumatic event and innovative research shows that it can be associated to
cardiovascular disease(4)

Literature review explore the idea that PTSD can disrupt the autonomic nervous
and increase incidence of stroke. (4) More scientific analysis is needed to find the
pathway associating PTSD to ischemic stroke and cardiovascular disease
problems.(4)

Post-traumatic disorder is considered a chronic stress condition that persists for a

long time or appears again at different time intervals when faced with another
traumatic situation. (5) General Recommendations to decrease PTSD response and
guidelines is still not available worldwide.(6) If left untreated and undiagnosed it
might lead to double burden effect on the economic and the productivity level(6)
since it affects the quality of life and lead to sleep disturbance, and increased
inflammation.(6) Psychological stress and mental health disorders are common
among many countries especially Lebanon and can be significant risk factors for
the progression of cardiovascular disease(7).PTSD is more prevalent in
environments that are exposed to wars, gun violence, political instability and
abuse.(7). Lebanon is facing micro and macro traumas such as the falling of the
Lebanese Lira Value, Covid-19 Pandemic in addition to the august 4, 2020 Beirut
Blast that left 218 people dead, and 6000 wounded with countless homeless and
increase in unemployment rate after the destruction of many restaurants (7)The
factors mentioned above led to an increase rate of mental health disorders. (7) In
addition it is important to follow a socio-cultural research that fits the Lebanese
population. (7) The government continuous neglect led to an increase of the crisis
(7) All of the above factors can be one of the determinants of PTSD. The aim is to
assist nutritional epidemiologists in an interventional framework and increase
awareness about mental health effects and find innovative methods to manage
cardiovascular disease complications.(7) Furthermore calculating the incidence
rate between PTSD and cardiovascular disease and creating advanced plans to
deal with Post-traumatic stress disorder.(7)

4. Research Problem

Is there an Incidence Rate between Post-traumatic Disorder and

Cardiovascular disease in Lebanese Elderly aged 65 years old?

5. Purpose of the study

The purpose of the study is to correct misconceptions of Post-Traumatic

Stress Disorder to show that stress can be the cause of cardiovascular disease
and the importance of prevention to decrease the burden on the government.

Objectives
1- Describe the population sample size number, and marital status.
2- Determine prevalence of post-traumatic stress disorder in Lebanon and it is
associated risk factors.
3- Determine e a socio-cultural sensitive research in which literacy level,
economic status, health behavior of trauma survivors are taken into
consideration.
4- Investigate the effect of genetic predisposition on blood lipid profiles.
5- Analyze the socio-demographic heterogeneity in the association between
PTSD and CVD.
6- Determine the mechanisms and pathways connecting PTSD and CVD.
7- Analyze the link between psychological stress and physical health.
8- Analyze the relationship between diabetes and CVD severity.
9- Determine the association between dietary habits and increased cardiovascular
rate.
10- Determine the connection between age, gender, and CVD diagnosis.
Evaluate if there is a relationship between high blood pressure and increased
ischemic stroke.
11- Explore the impact on reducing post-traumatic stress disorder symptoms on
CVD risk.
12- Examine how PTSD affects recurrence rates in individuals already
diagnosed with CVD.
13- Understand how can social support mitigate the risk of CVD in individual
with post-traumatic stress disorder
14- Test interventions tailored specifically for individuals PTSD such as therapy
and lifestyle modification to manage CVD.
15- Examine the impact of exercise on reducing CVD events following a
myocardial infarction.

1- Alternative Hypothesis Post-traumatic stress disorder is correlated with an

increased incidence of Cardiovascular disease diagnosis

Methodological

1.Type of study

A Prospective Quantitative Cohort Study followed for 1 year from October

2023 to October 2024 that will include 600 Lebanese elderly aged 65 years
or above who do not have metabolic problems such as diabetes, obesity, and
previous family history of heart disease, raised blood pressure and previous
mental health disorder. The population will be divided into two groups and
incidence will be measured with time a group will be exposed to a stressful
environment and another group will not be exposed to a stressful
environment in the present year 2023, participants are tracked over time for
the incidence of raised blood pressure ,ischemic stroke , and myocardial
infarction and the incidence events are recorded, after a 2 year in 2025 the
group exposed to stressful events will be divided into two groups a group
who is diagnosed with CVD and a group who didn’t develop cardiovascular
disease and the incidence rate will be calculated to check for disease
presence and absence, afterwards the relative risk will be calculated and
based on results, association between traumatic events and heart disease will
be verified or rejected

2. Methodology and Tools

2.1 Sampling

Probability Simple Random Sampling

2.2 Sampling Plan

Random Sampling will be the plan to ensure some precision in estimation of

the population. Each of the elements selected that make up the target of
population with no previous mental disorder, older than 65 with no
metabolic problems such as obesity, diabetes, and heart disease. Eligible
accessible and consenting population who consents to be part of the study
proposal who consents to be part of the study have an equal chance of being
chosen as part of the sample. Random Sampling eliminates bias and
promotes representativeness of the North Sample.

2.3 Sample size

The First Group

PO= percentage of people not exposed to trauma and having cardiovascular

disease outcome (North Region aged 65 and above).
 P1= percentage of people exposed to trauma and having cardiovascular
disease outcome. (North Region aged 65 and above).

Za-2.55

2B=1.2

Po-0.10

P1=0.20

P=p0 plus p 1/2/ p=0 25

• N= 2x (2.55 + 1.28) 2 - 0.25 (1-0.25) ( 0.10-0.20) 2

. N=2915

2.4 Inclusion Criteria/Exclusion Criteria

The inclusion criteria include Lebanese Elderly aged 65 years and above, not
taking hypertension medications and with no metabolic problems such as obesity,
diabetes, and heart disease. The exclusion criteria will include Males, and previous
diagnosis of Ischemic stroke, Myocardial Infarction and diagnosis of Mental
Disorder, and Lebanese population younger than 65. Inclusion includes patients
that provide informed consent for the study to be eligible for inclusion.

3.Dependent and Independent Variable

The Dependent variable is the presence/absence of cardiovascular disorder aged 65

years or older. This variable will be affected by the independent variable. The
presence/absence of post-traumatic events will be determined via a validated
Questionnaire translated into Arabic.

4. Instrument and Tools

Financial wellbeing scale
This scale indicates how secure and safe a person feels regarding his financial
situation. It is composed of 8 items rated from 1 to 10, with higher scores
indicating the least pressure felt from the current financial situation in the
country.We obtained a written permission to use this scale (current Cronbach’s
α = 0.931).

Lebanese anxiety scale (LAS)

This is a 10-item scale used to rule out anxiety. 7 questions are rated from 0 to 4
and 3 questions graded from 1 to 4; higher scores indicate more anxiety (current
CronbacPerceived Stress Scaleh’s α = 0.907).

Perceived Stress Scale validated Arabic translation of the 1 item Perceiv

.‫األسئلة التالية تستفسر عن مشاعرك و أفكارك خالل الشهر الماضي‬

.. ‫نرجو منك االجابة على جميع األسئلة‬

‫كثيرا دائما (في أغلب‬ ‫أحيانا‬ ‫نادرا‬ ‫اطالقا‬ ‫الحالة‬

)‫األحيان‬ )‫(أبدا‬

‫ الى أي مدى‬،‫ خالل الشهر الماضي‬.1

‫أحسست باالنزعاج بسبب حدوث أمر‬
‫غير متوقع؟‬

‫ الى أي مدى‬،‫ خالل الشهر الماضي‬.2

‫أحسست بعدم القدرة على التحكم في‬
‫األمور الهامة بحياتك؟‬
‫‪ .3‬خالل الشهر الماضي‪ ،‬الى أي مدى‬
‫أحسست بالتوتر و الضغط النفسي؟‬

‫‪ .4‬خالل الشهر الماضي‪ ،‬الى أي مدى‬

‫أحسست بالثقة في قدرتك على التعامل‬
‫مع مشاكلك الخاصة؟‬

‫‪ .5‬خالل الشهر الماضي‪ ،‬الى أي مدى‬

‫أحسست أن األمور تسير كما تريد؟‬

‫‪.6‬خالل الشهر الماضي‪ ،‬الى أي مدى‬

‫وجدت نفسك غير قادر على التأقلم مع‬
‫كل األمور الواجب عليك القيام بها؟‬

‫‪.7‬خالل الشهر الماضي‪ ،‬إلى أي مدى‬

‫تمكنت من التحكم في األمور التي‬
‫تزعجك؟‬

‫‪.8‬خالل الشهر الماضي‪ ،‬الى أي مدى‬

‫أحسست بأنك تملك زمام األمور(‬
‫مسيطر على كافة أمورك)؟‬

‫‪.9‬خالل الشهر الماضي‪ ،‬الى أي مدى‬

‫أحسست بالغضب بسبب أمور خارجة‬
‫عن تحكمك؟‬
 ‫ إلى أي مدى‬،‫ خالل الشهر الماضي‬.10
‫أحسست بأن الصعاب تتراكم عليك‬
‫لدرجة أنك لم تعد تستطيع التغلب‬
‫عليها؟‬

.Validated
Ali, A.M.; Hendawy, A.O.; Ahmad, O.; Sabbah, H.A.; Smail, L.; Kunugi, H. The
Arabic version of the Cohen perceived stress scale: factorial validity and
measurement invariance. Brain Sciences 2021, 11, 419, doi:

Socio-demographic Factors

Questions about Age, Sex, Income, education, and co morbidities, work status,
length of hospitalization, and religious status were analyzed to explore their
correlation to PTSD.
 The
PTSD Checklist-Specific Version (PCL-S) was used to evaluate manifestation of
PTSD.

The questionnaire is correlated with the objectives of the research and is divided
into the following categories, socio-demographic factors, validated Arabic
questionnaire about perceived stress, in addition to questions about previous
history of PTSD, depression, anxiety, and financial wellbeing scale in order to
minimize risk of confounding factors.

SocioEconomic Factors

• Household Crowding Index (HCI) will be calculated by dividing the number

of people living in the house by the number of rooms in the house, which
represents the family’s socioeconomic status (SES). A greater HCI indicates
a lower SES. The third section of the survey comprised the following
measures

5. Limitations

First, the sample is done on the North Region which can lead to selection bias ,
second the number of people expressing that they went through a traumatic
experience was low, the length of follow up is only one year, which can lead to
prognosis of CVD happening after one year, Furthermore, the impact of
supplementary posttraumatic psychopathology on cardiovascular health is largely
unknown. For instance, it is currently unknown whether certain trauma types
(interpersonal vs. non-interpersonal trauma), combinations following trauma that
are especially cardio toxic, and whether these combinations differ for men and
women, as well as the cardiovascular consequences. Furthermore, in order to
precisely determine the relevance of the association between PTSD and CVD,
research in a variety of population is essential.

6. Ethical Consideration

Participants are free to participate in the research, and they know the benefits,
including increased quality of life and a higher cost benefit to the community, the
risk and funding before they agree to join. The anonymity of participants is
protected, even if we know some participants their information is hidden from
everyone else.
7. Budget

Questionnaires for 2000 89,000 LL for one questionnaire

178,000 LL
Transport to the North Region 445,000 LL for transport from Beirut
10 employees for delivery of Total 4,500 LL
questionnaires
Researcher Assistant 1 1 52 weeks
1 day per week for a year Each day 1,780 LL
For statistical analysis For 52 days total
92,560,000 LL
Breakfast for team consisting 3 534,000 Breakfast for one
1,608,000 LL a day

8. Calendar

6 month 1st year

Post-traumatic Stress and x x
Cardiovascular Disease
Questionnaire x x
Pilot test X
Data collection X
Analyze the data X

Discussion of the data X

Writing the report X

9. Statistical Analysis

A dependent variable will be cardiovascular disease complications and the

independent variable will be post-traumatic stress disorder. Null hypothesis, there
is no relationship between post-traumatic stress disorder and cardiovascular
disease.

Continuous data will be analyzed according to mean, frequency, and standard

deviation. Data that doesn’t follow a normal distribution will be normalized
according to log10 or Chi-Square. Chi-square is used for bivariate analysis of
people with post-traumatic stress and people without post-traumatic stress.

Categorical variables will be demonstrated as percentages and numbers. Many

factors might contribute to cardiovascular complications such as age,
socioeconomic status, smoking, lifestyle, genetic predisposition or crowing index.
Post-traumatic stress contributing to cardiovascular disease is analyzed and it
shows a significant correlation at 95 percent Confidence interval with a p<0.05.
Reject nulls hypothesis and accept alternative hypothesis which shows that as post-
traumatic stress increases, cardiovascular complications such as hypertension,
coronary artery disease and stroke. Mcnemar test will be used to calculate the
variation of post-traumatic stress disorders among elderly >65 years old between 2
period before and after August 4, 2020, the date of Beirut Port nuclear explosion,
with 95 percent confidence interval and alpha equals 0.5. Independent T test will
be calculated to determine the variation of post-traumatic stress disorder between
males and female. All data analyzed were performed using IBM SPSS Statistics
"Statistical Package for the Social Sciences version 27.

Expected Outcome

Post-traumatic stress disorder will increase cardiovascular complications compared

to participants without post-traumatic stress. The quality adjusted life year will
increase, the change in survival with a measurement factors for an increase quality
of life. The cost-benefit of primary prevention of stress will maximize the net
social surplus and decrease the complications of cardiovascular disease. In
addition, increase of awareness to mental disorders will lead to better productivity
of employees and increase ability to go to work, which will generate more
investments. An accurate definition of post-traumatic stress disorder and a
validated diagnosis will decrease other complications such as depression, anxiety
and absenteeism from work, which will improve the economic status in the
community.

10. References
1-(El Hajj, M. (2021). Prevalence and Associated Factors of Post-Traumatic
Stress Disorder in Lebanon: A Literature Review. Asian Journal of Psychiatry,
63, 102800, n.d.)

2- Kim, K., Tsai, A. C., Sumner, J. A., & Jung, S. J. (2022). Posttraumatic stress
disorder, cardiovascular disease outcomes and the modifying role of
socioeconomic status. Journal of Affective Disorders, 319, 555-561. (n.d.)

3- Krantz, D. S., Shank, L. M., & Goodie, J. L. (2022). Post-traumatic stress

disorder (PTSD) as a systemic disorder: Pathways to cardiovascular disease.
Health Psychology, 41(10), 651.. (n.d.).

4 Nanavati, H. D., Arevalo, A., Memon, A. A., & Lin, C. (2023Associations

between Posttraumatic Stress and Stroke: A Systematic Review and
Meta‐analysis. Journal of Traumatic Stress., n.d.) -(

5-Rosman, L., Sico, J. J., Lampert, R., Gaffey, A. E., Ramsey, C. M., Dziura, J.,
... & Burg, M. M. (2019). Posttraumatic stress disorder and risk for stroke in
young and middle-aged adults: A 13-year cohort study. Stroke, 50(11), 2996-
3003. (n.d.).

6--(Zhang, S., Yuan, Y., Zhuang, W., Xiong, T., Xu, Y., Zhang, J., ... & Wang, Y.
(2022). Contributing Factors and Induced Outcomes of Psychological Stress
Response in Stroke Survivors: A Systematic Review. Frontiers in Neurology, 13,
843055., n.d.)

7-Zouki, E., Chahine, A., Mhanna, M., Obeid, S., & Hallit, S. (2022). Rate and
correlates of post-traumatic stress disorder (PTSD) following the Beirut blast
and the economic crisis among Lebanese University students: A cross-sectional
study. BMC psychiatry, 22(1), 1-10.. (n.d.

Letter of consent

First part contained a written consent form that confirmed the participants’
permission to voluntarily complete the survey, in addition to other ethical
considerations such as the insurance of the confidentiality and anonymity of the
respondents.

11. Appendix

Name of Investigator/s:Rasha Hijazi

Address: -----------------------

Phone Number: --------------

Site of the Study: ----------

It is a survey whose main objective is to determine the correlation between Post-

Traumatic Disorder and Cardiovascular Disease, an assessment of PTSD test is
also requested. The study of nutritional status consists of taking anthropometric
measurements such as height, weight, head circumference, waist to hip ratio, and
skin fold thickness.

A food frequency questionnaire will also be used to assess eating habits. The
target population is the elderly population above 65 in North Lebanon.

The study site will be located in the Rural Area of North Lebanon. Sampling will
be done from the list of Random Sampling the inclusion criteria will be elderly
aged 65 years and above, not taking hypertension medications and with no
metabolic problems such as obesity, diabetes, and heart disease and no previous
post-traumatic stress disorder.

This study aims first and foremost to sensitize families of elderly with the risk of
developing cardiovascular disease living in poverty. State intervention is also
required. It will take into account international and national directives concerning
all scientific research (Declaration of Helsinki, 1964).

The work will be done considering the respect of the participants, the anonymity
and the complete confidentiality of the information received. In addition, the
participants concerned will have the possibility of not answering the/several
questions which they deem affecting their privacy. At the end of the study,
participants have the right to have a copy of our results.

If consent, please sign:

DATE----------------

Name of researcher------------- Signature

Name of participant------- -------- Signature-----------