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Clinical Chemistry 50: 346-354, 2004. First published December 18, 2003; 10.1373/clinchem.2003.023853
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(Clinical Chemistry. 2004;50:346-354.)
© 2004 American Association for Clinical Chemistry, Inc.

Lipids, Lipoproteins, and Cardiovascular Risk Factors

Factors behind the Increase in Cardiovascular Mortality in Russia: Apolipoprotein AI and B Distribution in the Arkhangelsk Study 2000

Maria Averina1,a, Odd Nilssen1, Tormod Brenn1, Jan Brox2, Vadim L. Arkhipovsky3 and Alexei G. Kalinin4

1 Institute of Community Medicine, Medical Faculty, University of Tromsø, N-9037 Tromsø, Norway.
2 Department of Clinical Chemistry, University Hospital of Tromsø, Tromsø, Norway.
3 Semashko Clinic, Arkhangelsk, Russia.
4 Northern State Medical University, Arkhangelsk, Russia.

aAuthor for correspondence. Fax 47-776-44831; e-mail Maria.Averina{at}ism.uit.no.


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Cardiovascular mortality is markedly higher in Russia than in Western Europe and the US. Little is known about indicators of atherosclerotic risk in the Russian population. To our knowledge, this is the first study of apolipoprotein (apo) AI and B in Russia based on the WHO-IFCC standard.

Methods: We measured apo AI and B by immunoturbidimetric assay in 3694 men and women from Arkhangelsk, Russia, in 1999–2000.

Results: The age-related distribution of apo B was similar to that in other countries, whereas the apo AI profile was different. For men >=20 years, apo AI was considerably higher than in studies from other countries. Women had also relatively high apo AI concentrations, although the difference was not as pronounced as in men. The apo AI concentration was positively associated with age and lifestyle variables such as alcohol consumption and physical activity, and negatively associated with body mass index and self-reported myocardial infarction. {gamma}-Glutamyltransferase was positively associated with apo AI in both sexes.

Conclusions: The apparently favorable apolipoprotein profiles contrast with official death statistics indicating high cardiovascular mortality in Russia. High apo AI might indicate excessive alcohol consumption.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Mortality from cardiovascular disease (CVD)1 is markedly higher in Russia than in Western Europe and the US. Dramatic increases in mortality rates on an epidemic scale took place in post-Soviet Russia after 1991 (1). In the mid-1990s the cardiovascular mortality rate was double that of the US (1). After a temporary decrease in the late 1990s, cardiovascular mortality in Russia continues to increase (2). In an earlier report (3) we showed that such factors as total cholesterol concentrations, blood pressure, and smoking had little predictive value. These findings supported the results of former studies in Russia (4)(5)(6). High cardiovascular mortality and its significant fluctuations in post-Soviet Russia seemed to be only partially associated with the "classic" risk factors identified in epidemiologic studies in Western Europe and the US.

Little is known, however, about other indicators of atherosclerotic risk in the Russian population. Low serum concentrations of apolipoprotein (apo) AI, the main protein component of HDL, and increased concentrations of apo B100, the main protein component of LDL, have been reported as CVD risk factors in case–control studies, studies of patients undergoing angiography, and in prospective studies (7)(8)(9)(10)(11)(12)(13)(14)(15)(16). Some authors have concluded that apo AI and B were better indicators of atherosclerotic risk than other serum lipids (9)(10)(13). A study of patients with angiographically confirmed coronary heart disease and without apparent risk factors has emphasized the importance of investigating apo AI in populations with low classic risk profiles (12). Significant differences in lipid and apolipoprotein profiles have been found between Estonian and Russian men living in Estonia (17). These results have emphasized the need for obtaining data to establish apolipoprotein reference values in Russia. The aims of the present study were to determine the distribution of apo AI and B and to identify their determinants in an adult Russian population.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
study population
The town Arkhangelsk is the center of the Arkhangelsk region, the largest northern region of the European Russia. In 1999, the population of the Arkhangelsk town was 170 000 men and 197 000 women (0.3% of the general Russian population in 1999) (18).

No population register was available for medical research in Arkhangelsk. Outpatient clinics in Russia provide primary medical care to the general population according to territorial and occupational principles. We therefore decided to consecutively recruit residents registered at one of the outpatient clinics in Arkhangelsk. Pensioners were recruited through the clinic’s register. Working people and students were consecutively invited either through obligatory annual medical examinations or through their places of work or study. Inclusion criteria were being a Russian resident and age >17 years. Altogether 1962 men and 1732 women >=18 years of age participated in the study in 1999–2000 and had their apolipoprotein concentrations measured. The age distribution of the study population was close to that of the total Russian adult population in 2000, and marital status was similar to that the general population of the Arkhangelsk region (3). Participants younger than 25 years were mainly students (72% of men and 61% of women). The majority of men 25–59 years of age were seamen and harbor workers (86%), whereas women of this age were mainly civil employees and factory workers (73%). Civil employees were predominantly occupied in educational and healthcare systems. Approximately 84% of all examined civil employees were women, and only 16% were men. The official statistical data for the entire Arkhangelsk region in 1999 (18) showed the same skewed sex distribution in these professions (84–85% women and 15–16% men). In the age groups over 60 years there were mostly pensioners (80% of men and 88% of women). The proportion of pensioners in the study population was the same as in the Arkhangelsk region (3).

ethics approval
The study was approved by the Regional Ethical Committee, Norway. Verbal informed consent was obtained from all participants.

questionnaire, physical examination, and laboratory analyses
All participants answered a 6-page questionnaire (111 items) covering education, marital status, occupation, family diseases, smoking, and physical activity at work and leisure. Participants answered questions on their frequency of alcohol consumption (categories: never, once a month, two to four times per month, two or more times per week) and on their weekly consumption of beer, wine, and vodka in alcohol units (1 AU = 13.8 g of pure alcohol). Physical activity was assessed at work and at leisure. Three categories were used for analysis: sedentary, moderate, and high physical activity. A sedentary job and sedentary leisure lifestyle were defined as sedentary physical activity. Walking, cycling at least 4 h per week during leisure time, or a job requiring considerable walking were defined as moderate physical activity. High physical activity included amateur sport activities at least 4 h per week, regular physical training several times per week with participation in sport competitions, or a job requiring considerable walking, lifting, and physical strain.

Dietary habits were estimated by four questions concerning how often participants ate fresh fruits and vegetables, fish, meat and meat products, and milk and milk products (never or very rarely, once a week, two to three times per week, four to five times per week, or almost daily). Bread consumption was assessed by a separate question that asked how many pieces of bread (all bread types) participants ate daily (<2, 2–4, 5–6, 7–12, >=13).

Self-reported information about coronary heart disease (angina pectoris, myocardial infarction), stroke, and diabetes mellitus was obtained. Participants reported use of cardiovascular medicines without specification of the types of medicines. Body height, weight, and blood pressure were measured, the latter with a DINAMAP-R automatic device.

Nonfasting venous blood samples were drawn and centrifuged within 15–25 min at the laboratory servicing outpatient clinics in Arkhangelsk. Serum was stored at -20 °C for 3–4 weeks and then transported to Norway in boxes containing freezing elements by a 5-h flight. Serum was kept at -80 °C before analyses. All laboratory measurements were performed in Norway at the Laboratory of the Department of Clinical Chemistry, University Hospital in Tromsø.

Apo AI and B were assayed by an immunoturbidimetric method with polyclonal sheep anti-human apolipoprotein antibodies (Roche). Methods for measurement of apolipoprotein were standardized against the WHO/IFCC SP-07 standard (19)(20). The laboratory used both internal and external methods of quality control. The analytic CV was <3% for both apo AI and apo B measurements. External quality control showed apolipoprotein values within the established control limits.

HDL-cholesterol was measured by the homogeneous enzymatic colorimetric test (polyethylene glycol-cholesterol esterase, peroxidase) with a CV of 3%. This method meets the goals of the 1998 NIH National Cholesterol Education Program for acceptable performance. The results of the method correlate well with those obtained by precipitation-based methods (21). All analyses were performed in a Hitachi 917 analyzer.

statistical methods
The two-sample t-test was used to compare the results for men and women. Pearson correlation coefficients and forward stepwise linear regression analyses were performed separately for each sex with use of SAS statistical software package 8e (22) to study the relationships between the apolipoproteins and other variables. A 5% significance level was used for reminding or removal from the final regression model.

The independent variables introduced in the initial regression model comprised demographic characteristics (age, civil status, occupation), education (categories: 1, incomplete and complete secondary education; 2, secondary professional education; 3, unfinished university; 4, high education; i.e., complete university education), previous and present diseases (myocardial infarction, angina pectoris, stroke, diabetes), diseases in parents and siblings (myocardial infarction, angina pectoris, stroke), cardiovascular medication (no/yes), lifestyle variables (active and passive smoking, physical activity), alcohol consumption (in general and separate for each type of beverage), and physical measurements [body mass index (BMI), serum {gamma}-glutamyltransferase (GGT), albumin, and serum lipids].

Results of the regression analysis were presented as ß-coefficients. The formula ß x 100 was introduced to make the presentation of the results easier. These coefficients show the change in apolipoprotein concentrations (in g/L, multiplied by 100) if the independent variables change by one unit. The following independent variables remained in the final regression models for apo AI in one or both of sexes: age (years), BMI (kg/m2), physical activity (sedentary, moderate, high physical activity), self-reported myocardial infarction (no/yes), smoking (no/yes), high education (vs secondary education), serum albumin (g/L), GGT (U/L), total cholesterol (mmol/L), and triglycerides (mmol/L). Alcohol variables that remained in the final analysis were frequency of alcohol intake (see previous categorization of the variable), weekly consumption of vodka (in AU), and weekly consumption of beer (in AU).

The final regression model for apo B contained the following independent variables: daily bread consumption (see previous categorization of the variable), weekly beer intake (in AU), meat and meat products consumption (see previous categorization of the variable), age (years), BMI (kg/m2), high education (vs secondary education), smoking (no/yes), GGT (U/L), serum albumin (g/L), and triglycerides (mmol/L).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The baseline characteristics of the participants are listed in Table 1 . The age-standardized prevalence of self-reported CVD and stroke in the study population was 130.7 per 1000 participants (age-standardized to the general Russian population in 1998). This number agrees well with the official data on prevalence of circulatory diseases in the northwestern regions of European Russia in 1998 (132.9 per 1000 citizens) (23).


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  		Table 1. Baseline characteristics of participants in the Arkhangelsk Study 2000.

Approximately 10% of the study population reported use of cardiovascular medicines. Exclusion of those who took medicines did not change the apo AI and B distributions substantially. Thus, we decided to present the final results from all of the participants.

Apo AI and B distributions were close to gaussian (Table 2 ). Apo AI concentrations were significantly lower in all age groups of men than in women (P <0.0001). In men, apo AI concentrations increased steeply between 18 and 29 years, plateaued at 30–59 years, and decreased gradually after 60 years. In women, apo AI concentrations plateaued at the age of 20 years. As in men, apo AI decreased in the oldest age group of women.


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  		Table 2. Apo A-I and B (g/L) serum concentrations in men and women: The Arkhangelsk Study 2000.

Apo B concentrations increased in men from the age of 18 to 59 years and tended to decrease in the older age groups. In women, there was a continuous increase in apo B concentrations with age. Men had higher apo B concentrations than women in all age groups from 20 to 49 years (P <0.0001), but there was a reverse relationship in the oldest age group (P <0.0001).

We have presented the regression analysis of apo AI as two models (Table 3 ): the first model is without serum lipids, the second model includes total cholesterol and triglycerides.


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  		Table 3. Multiple linear regression analysis of apo AI (g/L) in the Arkhangelsk Study 2000.2

The first regression model included two different types of alcohol variables: frequency of alcohol intake (without consideration for volume and type of beverage), and volume of vodka and beer consumed per week. Volume of wine consumed per week showed no significant association with apo AI and was not included in the model (only 9% of men reported any intake of wine).

Model 1 (without alcohol variables) explained 10.4% and 10.3% of the apo AI variance in men and women, respectively. When the alcohol frequency variables were added, r2 increased to 12.4% in men and 12.6% in women. When the frequency variables were substituted by the alcohol volume variables, r2 was 12.9% and 11.3%, respectively. When both types of alcohol variables were added, the model explained 13.5% of apo AI variance in men and 12.8% in women (Table 3Up ).

A frequency of alcohol intake of "2–4 times per month" was associated with increases in apo AI of 0.060 and 0.077 g/L in men and women, respectively. An alcohol intake of "2 times per week or more" was associated with increases in apo AI concentrations of 0.064 g/L in men and 0.129 g/L in women (vs abstainers).

Serum GGT was significantly associated with apo AI in both sexes. However, when the analysis was done separately only for lifetime abstainers, we found no association between GGT and apo AI (data not shown).

In men with self-reported myocardial infarction, apo AI was 0.111 g/L lower than in healthy men (model 1). In women the association between apo AI and myocardial infarction was also negative, but not significant. Moderate physical activity showed a positive association with apo AI in both sexes. Men with high physical activity had apo AI concentrations 0.072 g/L higher than those with a sedentary lifestyle. In women this association was not significant (relatively few women reported high physical activity).

Inclusion of serum lipids in the analysis (model 2) increased r2 substantially in both sexes. Apo AI was strongly positively associated with total cholesterol and negatively associated with triglycerides.

The correlation coefficients between apo AI and HDL were 0.75 in men and 0.81 in women, respectively, and those between apo B and total cholesterol were 0.91 in men and 0.90 in women. Because of the high correlation coefficients, HDL- and total cholesterol were not included in the regression analyses for apo AI and B, respectively.

Apo B was positively associated with meat consumption and negatively associated with bread consumption in both sexes (Table 4 ). Consumption of vegetables, fruits, fish, milk, and coffee was not associated with apo B concentrations. In men, apo B was positively associated with smoking and beer consumption. Apo B concentrations were positively associated with GGT in both sexes; however, we found no significant association between GGT and apo B when the analysis was done separately for lifetime abstainers.


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  		Table 4. Multiple regression analysis of apo B (g/L) in the Arkhangelsk Study 2000.2

comparison with other studies
The results of our study were compared only with population studies that used the WHO-IFCC standard for apolipoprotein measurements. Only studies with means for total cholesterol and BMI similar to our population were selected: the National Health and Nutrition Examination Survey (NHANES) III Study (24) and the Framingham Offspring Study in the US (25)(26). A Finnish study (27) reported HDL-cholesterol values similar to those in our study, but the participants had higher total and LDL-cholesterol. Despite this, we used this study for comparison.

The pattern of apo AI distribution was different in our study compared with those reported in other studies (Fig. 1 ). In men, there was an abrupt increase in apo AI at the age of 18–30 years, whereas in other studies there was a relatively gradual increase or no age-dependent increase. Furthermore, actual apo AI concentrations were markedly higher in all age groups of men in Arkhangelsk compared with other studies. For the youngest men (<20 years) the results were similar to those in the NHANES III Study (24). Women 20–29 and 40–59 years of age had apo AI concentrations similar to the values in the Finnish study (27), but markedly higher than those reported in the two studies from the US (24)(25).



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  		Figure 1. Distribution of apo AI and B median values (g/L) by age in men and women in Arkhangelsk compared with other studies.

x, the Arkhangelsk Study; {triangleup}, the Framingham Study (24)(25); *, the NHANES III Study (23); {circ}, the Finnish study (26).

The pattern of apo B distribution in men was almost equal to that in the Framingham Offspring Study and in the NHANES III Study (24)(25), i.e., increasing with age, slightly decreasing in the oldest age groups, higher apo B concentrations in young men compared with women of the same age, and the reverse relationship after the age of 60 years. Women >30 years of age had the same concentrations and pattern of apo B distribution as in the NHANES III Study, whereas those under 30 years had lower values (24).


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
study advantages
To our knowledge, this is the first report of apo AI and B distributions in Russia based on the WHO-IFCC Reference Materials. The study was carried out in a region with total mortality (15.1 per 1000 citizens) and cardiovascular mortality (8.3 per 1000 citizens) rates similar to those in Russia as a whole in 2000 (15.4 and 8.5 per 1000 citizens, respectively) (18)(28). The age-standardized prevalence of self-reported CVD in the study population corresponds well with the official data for the northwest of Russia.

methodologic issues
To avoid "between-laboratory differences" we compared our data only with reports based on the WHO-IFCC Reference Standard. Storage of serum at -80 °C does not affect apo AI and B values (25)(26)(29). Blood samples in our study were nonfasting. The NHANES III Study showed no significant difference in apo AI and B concentrations between fasting and nonfasting individuals stratified by age and sex (24).

Taking into consideration the large difference in apo AI concentrations between our sample and other studies, we investigated the possibility of a methodologic bias. External quality control at the laboratory showed that apo AI values were within the established control limits. We also believe that the abrupt increase in apo AI in young men could hardly be explained by a systematic laboratory difference.

study limitations
One limitation of the study is that the method used to establish a study population was not ideal. Because a population register was not available for medical research in Arkhangelsk, we had to recruit participants through the primary healthcare system. However, the demographic characteristics of the study population were close to those for the general Arkhangelsk region population. Furthermore, we compared the values for classic CVD risk factors in our population with the results from other population-based studies in Russia (the MONICA Study in Moscow and in Novosibirsk) (3) and found no substantial difference between these population samples. However, we cannot exclude the possibility of different distribution of CVD risk factors in some geographic regions of Russia, especially in small nationalities with mortality rates higher than the average for Russia. Our population was recruited from a region with a mortality rate similar to the average mortality rate for Russia as a whole.

Another limitation of the study is that recruitment of participants during the obligatory medical examination might have led to underreporting of alcohol consumption.

interpretation of the findings
The apo AI and B profiles appeared to be favorable in our study participants. These results are consistent with our previous work indicating that, regardless of the high cardiovascular mortality, the values for the classic cardiovascular risk factors are more favorable in the examined Russian population than in similar studies from Western Europe and the US (3).

In addition, there was a different pattern of apo AI distribution in young Russian men compared with men in other studies. The abrupt increase in apo AI in young men seemed to be lifestyle- rather than age-dependent. There were considerable socioeconomic differences between the 18–19 and 20–39 age groups: the majority of men in the youngest age group were students (97%), whereas 73% and 90% of men in the age groups 20–29 and 30–39 years, respectively, were well-paid seamen and workers. Although reported physical activity decreased gradually with age, self-reported vodka consumption doubled from 3.3 AU/week in men 18–19 years to 6.3 AU/week in men 30–39-years of age. This increase is somewhat parallel to the increase in apo AI (Fig. 2 ).



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  		Figure 2. Median apo AI concentrations and weekly vodka consumption in men: The Arkhangelsk Study 2000.

{blacktriangleup}, vodka in AU/week (1 AU = 13.8 g of pure alcohol); {blacksquare}, median apo AI (g/L).

Furthermore, the frequency of alcohol intake and the amount of alcohol consumed were important predictors of apo AI in both sexes. This supports the results from other studies, in which apo AI and HDL-cholesterol concentrations were positively associated with alcohol consumption (30)(31)(32)(33). Daily and weekend drinkers (males) in our study had apo AI concentrations similar to those of the same groups of male drinkers in a study from Australia (34).

GGT was significantly positively associated with apo AI in both sexes. GGT is known as a biological marker for alcohol consumption, but it is also reported as a risk factor for stroke, hypertension, and diabetes (35)(36)(37). GGT concentrations in Russian men and women were double those in similar studies in Norway, indicating high alcohol consumption (data not shown). Mean (SD) self-reported alcohol consumption in our study was 7.5 (8.7) AU/week for men and 2.3 (3.8) AU/week for women, which corresponds to 6.2 and 1.9 L of pure alcohol/year. The discrepancy between the self-reported moderate alcohol intake and the high GGT values indicates a possible underreporting of alcohol consumption. Previous studies of alcohol consumption showed that participants tended to underestimate alcohol intake, reporting only ~40% of actual consumption (38). According to a WHO report, consumption of pure alcohol per adult (15 years and older) adjusted for the unrecorded production was much higher in Russia in the mid-1990s than in Finland and the US (14.5 L/year vs 9.8 and 9.0 L/year, respectively) (39).

Several prospective studies showed that heavy alcohol consumption was associated with higher risk of sudden cardiovascular death and fatal myocardial infarction (40)(41)(42)(43). It has been expressed that many deaths from arrhythmias and cardiomyopathies in middle-aged Russian men might have been classified as coronary heart disease (44). The quality of cause-of-death reports in Russia has not been investigated since the late 1980s. The role of binge drinking as a possible risk factor for cardiovascular death from arrhythmias and cardiomyopathies was emphasized in a report about increased cardiovascular death on weekends in Moscow (45) and in a similar study in Lithuania (46). In these cases the traditional CVD risk factors would have little predictive value.

The epidemic of CVD in Russia has another striking peculiarity. The considerable increase in cardiovascular mortality took place after the collapse of the Soviet Union in 1991 and paralleled increases in mortality rates from external causes of death, such as fatal alcohol poisonings, accidents, and violence. Increasing alcohol consumption in a situation with economic and social instability, rising poverty, and dissolution of social controls has apparently played a substantial role in the rising mortality from external causes.

At the same time results of population studies in Russia have shown little predictive value of the traditional risk factors in explaining the excess in CVD mortality rates (3)(4)(5)(6). The Lipid Research Clinics Study (6) also found higher HDL concentrations in Russian men compared with US men, and a positive association between high HDL and all-cause mortality in Russia. These findings indicate a strong influence of other powerful factors that are associated with increased risk of death as well as with high HDL and apo AI concentrations. It is possible that high apo AI and HDL-cholesterol concentrations serve more as markers of liver problems secondary to excessive alcohol use. We believe that further prospective studies are necessary to elucidate the set of risk factors responsible for the high mortality rate in Russia.


   Acknowledgments
 
This study was supported by the Norwegian Research Council. We thank colleagues from the Department of Clinical Chemistry, University Hospital of Tromsø, Norway, and colleagues from the Semashko outpatient clinic in Arkhangelsk, Russia.


   Footnotes
 
1 Nonstandard abbreviations: CVD, cardiovascular disease; apo, apolipoprotein; AU, alcohol unit(s); BMI, body mass index; GGT, {gamma}-glutamyltransferase; and NHANES, National Health and Nutrition Examination Survey.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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