1C: Cardiovascular health and

risk

1: Risk, correlation and cause

2: Investigating the causes of CVDs
Objectives:

• Understand why people’s perception of risk is often different from actual

risks, including underestimating and overestimating the risks.

• Be able to distinguish between correlation and causation.

Recall & Reproduction

1. What is cardiovascular disease (CVD)?

2. List three common risk factors associated with CVD.

3. Define the term "correlation" in the context of health studies.

There are many lifestyle factors that can increase
the risk of cardiovascular disease (CVD)
• CVD is a general term for conditions affecting the heart and
blood vessels
• It is usually associated with
• Atherosclerosis; the formation of hard plaques in the artery
lining
• Thrombosis; the formation of blood clots in the arteries

Risk factors are factors that can be linked to

an increased risk of a disease
• Exposure to a risk factor doesn’t guarantee that an individual
will suffer a disease, e.g. a person who smokes regularly isn’t
guaranteed to develop lung cancer but their risk compared to
someone who doesn’t smoke is much higher
• Certain risk factors are correlated with certain diseases,
but correlations are not always causations
Risk factors can be

• Aspects of a person’s lifestyle such as the food they eat or whether or not they drink
alcohol
• Substances in a person’s body or environment such as air pollution in a crowded city or
asbestos in old buildings
• Genetic predispositions to developing certain diseases
• Other biological factors such as age or biological sex

Many diseases are caused by the interaction of a number of factors

• E.g. the chance of developing CVD is higher in individuals who have a diet high in
cholesterol, don’t exercise regularly, and smoke; all of these behaviours increase the
likelihood of damage occurring to the arteries
Some factors, such as those related to
lifestyle, are to some extent under the
control of the individual
• It is usually possible to make decisions about diet,
smoking, alcohol intake, and exercise levels
• Note that scientists are becoming increasingly aware
that the best choices are easier to make for some than
others; unhealthy food choices are often cheaper and
easier, and not everyone has time to exercise

Other factors are outside of an individual's

control, such as genetics, biological sex, and
age
Engage and explore together to answer the question:

• Explain how cardiovascular disease can be considered a multifactorial

disease. Include at least three different factors that contribute to its
development.

• Describe the difference between correlation and causation in health

studies. Provide an example related to CVD to illustrate your point.
Perceived vs Actual Risk

Ø Risk is defined as the chance or probability that a harmful event will

occur
Ø The statistical chance of a harmful event occurring needs to be
supported by scientific evidence gained from research
An individual's perception of risk may be different to the actual risk of something occurring

•Risk can be overestimated because of factors such as

•Misleading information in the media
•Overexposure to information
•Personal experience of the associated risk
•Unfamiliarity with the event
•The event causing severe harm
•Lack of enjoyment of an activity

•Risk can be underestimated because of factors such as

•Lack of information
•Misunderstanding of factors that increase the risk
•A lack of personal experience of the associated risk
•Unfamiliarity with the event
•The harm being non-immediate
•Enjoyment of an activity
The statistical chance of an event
occurring often bears little resemblance to
someone's perception of the risk
E.g. the global annual risk of being
killed in a road accident is 1 in 1 547,
and the global annual risk of death due
to crashing during a flight is 1 in 4.5-
5.5 million; despite this people are far
more likely to have a fear of flying
than a fear of driving
Epidemiology

Epidemiology is the study and analysis of the distribution, patterns and determinants of health and
disease conditions in defined population.
 2: Investigating the causes of CVDs

Objectives:

Be able to evaluate the design of studies used to determine heaalth risk

factors including sample size, sample selection used to collect data that are
both valid and reliable
Write down the different steps for a scientific method

The basic process involves

• making an observation
• Background research
• forming a hypothesis
• conducting an experiment
• analyzing the results.
• Draw a conclusion
1. Define and explain:
• Longitudinal studies
• Meta data analysis
• Valid
• Precise
• Reliable
• Biased
• Evaluate

2. List and explain the non-modifiable risk factors for CVDs.

Quantitative Data on Illness

Analyzing data on illness and mortality

• Analyzing data on illness and mortality is an essential part
of the study of risk factors.
• It is important to remember that correlation between a
risk factor and a diseases does not always mean that a
causal relationship exists.
• Scientists cannot assume that because there is
correlation between variables that one has caused the
other
• Many other factors will influence the prevalence and
likelihood of disease and these factors need to be taken
into account when analysing and interpreting data
Describing data

This means identifying

trends and stating what the results show
e.g. the data show that the oldest age group
has the highest relative risk of heart disease
• When describing data, it is always good to use
numbers from the data to back up your descriptions,
e.g. the data show that the oldest age group of 80+ has
the highest relative risk of heart disease of 2.4
Drawing conclusions from data

This means working out what the data show about

the relationships between variables, e.g. the data show that
there is an association, or correlation, between age and the
relative risk of heart disease
• Conclusions should always be limited to what the data show
• Causal relationships cannot be concluded from one data set, e.g. it cannot
be concluded from one study that older age causes an increase in the relative
risk of heart disease
• Conclusions cannot be extrapolated beyond the setting of a study e.g. a
study carried out in 40-50 year old adults cannot be applied to people over 70,
and a study carried out in mice cannot be directly applied to humans
Evaluating the validity of data

•Larger sample sizes are more likely to give valid results as the sample is more likely to be representative of the
population in question

•Results are considered to be valid if they measure what they set out to measure, i.e. they are not influenced by
external variables or poor experimental design, and have been analyzed correctly.

•Statistical analysis should be used to check that any differences between results are statistically significant.

•Some studies need to have a control with which to compare the results
•E.g. when testing a drug to treat heart disease, a control group that is not given the drug should be included in
the study to ensure that any effect shown is due to the drug and not any other factor.

•Studies should be repeated, or there should be many studies that show the same result, before conclusions can be
drawn.

•The study should be designed to control any variable that is not being tested

•Researchers should not be biased, i.e. looking for a particular outcome

•This could be a problem if someone is being paid to come up with a particular result
 Recognizing conflicting evidence:

Evidence from one study is not

enough to conclude that a risk factor
is a risk to health or associated with a
particular disease

Studies similar in design would need • Such an analysis is referred to as a meta-analysis

to be analyzed together to make links

Similar conclusions would need to be

drawn from all studies in order to
accept the findings

• Conflicting evidence is that which shows a different pattern to the evidence gained elsewhere
Conflicting evidence may be found • When conflicting evidence arises, more research is needed to show which pattern is correct
that leads to a different conclusion • Conflicting evidence is often a sign that other variables are involved
 Correlation is
where a change in
Beware of mixing up
one variable occurs
correlation and
at the same
causation.
time as a change in
another variable.

Causation is where
Just because two
the change in one
factors correlate
variable causes the
does not mean one
change in another
causes the other.
variable.
Designing Studies

Features of a Good Study on Illness:

There are a number of factors to consider when evaluating the design of a study.

1. The sample of people included in the study

• Sample size should be representative of the population involved; larger samples are more
likely to be representative.

• Some epidemiological studies are carried out over a long time. These longitudinal studies are
very valuable because they follow the same group of individuals over many years, this means
the impact of their known lifestyle on their health can be tracked over time.
• Randomly selecting participants removes bias and increases the likelihood of a representative sample.

• Selecting people from among friends or from among people at a gym, for example, is likely to
select people who have similar lifestyles; this would be a biased sample
2. Control variables; the more variables that have been controlled, the more reliable and valid the data.

• Reliable data can be reproduced by repeating an experiment.

• Valid data has only tested one independent variable whilst all other variables are controlled

3. Avoiding bias; there should be no bias involved in the collection or analysis of data.

• Bias in data can come from human sources, e.g. by selecting a non-random sample or manipulating data to
emphasize a certain outcome.

• Bias can be a problem when, e.g. scientists are employed by a company that desires a particular result, or
when scientific funding is dependent on specific outcomes

4. Controls; the use of an experimental control provides a point of comparison and ensures that the results are
due to the variable of interest

• An experimental control condition in a study should be the same as every other condition except that the
independent variable should be absent, e.g. in a drug trial the control group would be identical to the
group receiving the trial drug, except that they would be given a sugar pill instead of the drug; this is
known as a placebo
5. Repetition; repeats of the data need to be taken within a study, and similar results should be collected.

• Similar results are reliable

6. Reproducible; it should be possible to reproduce a set of findings by repeating an entire investigation.

• This is why scientists always write up the method used in a study.

Quick review: List the risk factors for CVDs.
 3: Risk factors for CVD

Objectives:

Know how factors such as diet, high blood pressure,

smoking and inactivity increase the risk of CVD
Engage and explain:

1. What is the difference between modifiable and non-modifiable risk factors?

2. Give two non-modifiable and two modifiable risk fafctors for atherosclerosis.

3. For each factor you have chosen, explain how it increases the risk of developing
atherosclerosis and CVDs.
Smoking and artherosclerosis: The chemicals inhaled when a person smoke cause
damage to the heart and blood vessels that makes it more likely to develop atherosclerosis, or
plaque buildup in the arteries. Any amount of smoking, even occasional smoking, can cause this
damage to the heart and blood vessels.
Overweight and atherosclerosis
Obesity is a well-known risk factor for atherosclerosis, and accelerates atherosclerosis by many
mechanisms such as increase in blood pressure and glucose level, abnormal lipid profiles, and systemic
inflammation.
 4: Diet and cardiovascular health

LEARNING OUTCOMES:

1. understand how people use scientific knowledge about the effect of diet, including
obesity indicators, such as body mass index and waist-to-hip ratio, exercise and smoking
to reduce their risk of coronary heart disease.

2. be able to analyse data on the possible significance for health of blood cholesterol
levels and levels of high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs)

3. know the evidence for a causal relationship between blood cholesterol levels (total
cholesterol and LDL cholesterol) and cardiovascular disease (CVD)
A risk factor is any factor that increases the chance of developing a particular condition or disease
• An increase in a risk factor does not guarantee the development of disease, but increases the
risk
• An example of a risk factor for the incidence of CVD is increased blood cholesterol

An increase in the presence of a risk factor would be expected to lead to increased incidence of disease
• The incidence of disease describes the number of cases of a disease that occur within a
particular group of people within a given time
Engage and explore:

1. List two potential health risks associated with obesity.

2. What does BMI stand for?

3. How is BMI calculated?

4. Describe how BMI categories (underweight, normal, overweight, obese) are determined.

5. What is the significance of the waist-to-hip ratio in assessing health?

BMI (body mass index), is based on the height and weight of
a person, is an inaccurate measure of body fat
content and does not take into account muscle mass, bone
density, overall body composition, and racial and sex
differences
Now waist-to-hip ratio (WHR) is used to
see if a person is overweight, and if that
excess weight is putting the health at risk.
Unlike body mass index (BMI), WHR
determines how much fat is stored on
waist and hips.

People who carry more weight around

their midsection (an apple-shaped body)
are at higher risk for heart disease, type 2
diabetes, than those who carry more of
their weight in their hips and thighs (a
pear-shaped body). Even if BMI is within a
normal range, risk for disease may be
increased.
Waist-to-hip-ratio is a quick and easy way
to check how much weight carried around
the middle. It’s just one of several
measures — along with BMI — that can
evaluate your weight and health.
Tackling obesity:
A diet high in sugar, salt, fat and refined
carbohydrates increases the risk of
obesity. A diet rich in vegetables, fruit
and whole grains reduces the risk of
obesity. Exercise has many health
benefits and can help manage our weight
- but what we eat and how much we eat
is even more important.
Think pair and share:
1. What do the acronyms LDL and HDL stand for?

2. What is the primary function of LDL in the body?

3. Compare and contrast LDL and HDL in terms of their roles in the body.

4. Describe how high levels of LDL can impact cardiovascular health.

5. Explain the relationship between diet and cholesterol levels.

Cholesterol:

•Cholesterol is a type of lipid produced in the body

•Cells require a source of cholesterol for cell membrane functioning, sex hormone structure, and the
synthesis of bile.

•Cholesterol is transported around the body as lipoproteins

• Lipoproteins are molecules composed of lipid and protein
• There are two types of lipoproteins; high density lipoproteins (HDLs) and low density
lipoproteins (LDLs)

•The balance of HDLs and LDLs in the blood is thought to be an important factor in the risk of
developing heart disease
High density lipoproteins:

•HDLs contain unsaturated fat, cholesterol, and protein.

•These molecules transport cholesterol from body tissues to the liver to be recycled or excreted; they are
responsible for reducing blood cholesterol levels when it is too high.

•HDLs are also thought to contribute to the removal of cholesterol from the fatty plaques that form during
atherosclerosis

Low density lipoproteins

•LDLs contain saturated fat, cholesterol, and protein.

•The role of LDL is to move cholesterol from the liver into the bloodstream where it remains until it is required by the
cells; they increase blood cholesterol levels when it is too low.

• LDLs bind to receptors on cell surface membranes, enabling them to be taken up by the cells that need them
and removing cholesterol from the blood
• High levels of LDLs can lead to blockage of these membrane receptors, causing blood cholesterol to rise
Lipoproteins and heart disease

•LDLs are often thought of as 'bad cholesterol'

• When your body has too much LDL cholesterol the membrane receptors on the surface of cells are blocked,
leading to an overall rise in blood cholesterol
• Cholesterol contributes to the formation of plaques in the arteries

•High density lipoproteins are often thought of as 'good cholesterol'

• This is because HDLs carry cholesterol to the liver where it is broken down and excreted, therefore lowering
overall blood cholesterol levels

Rather than one being bad and the other good, in reality it is the ratio of LDLs to HDLs that is important; the healthy
ratio is thought to be roughly 3:1 of LDL:HDL

• It is thought that an LDL:HDL ratio larger than 5:1 increases the risk of heart disease
•While diet is a factor in determining the production of LDLs and HDLs in the body, the way in which the cells process
lipids is also thought to be important
•It is important to be able to analyze data on the link between lipoproteins and CVD
Evaluate your understanding:
NOTE-

When dealing with data there are a few important things to remember:

•It is always a good idea to include numbers when you are describing a data
set.

•Correlation is not causation; when drawing conclusions it is always best to

say 'there is a correlation' or 'there is an association' between two variables
rather than stating that one has caused the other.

•Look for clues about the validity of the experiment. Is the sample
representative? Have other variables been controlled? Has statistical analysis
been carried out?
Correlation vs Causation:

Evidence linking blood cholesterol to CVD

•High cholesterol is listed as one of the five main risk factors for heart disease by many research studies and
organizations such as the British Heart Foundation and the NHS.

•There is evidence of a correlation between high blood cholesterol levels and an increased risk of CVD
• Medical treatments such as statins, which reduce blood cholesterol levels also reduce risk of heart disease
• Diets high in saturated fats, which tends to raise LDL cholesterol levels in the blood, have been linked to
increased CVD events
• A significant reduction in total blood cholesterol levels is linked to a decrease in major coronary events
• Arterial plaque regression has been observed alongside blood lipid-lowering therapy, which has led to a
reduction in major cardiovascular events

•Note that when considering scientific evidence it is essential to remember that correlation is not the same as
causation; a connection between two events, e.g. a diet high in saturated fat and raised LDL cholesterol, may not
mean that one has caused the other

• It may be that there is a third variable that has not been measured that is influencing levels of LDL
cholesterol, e.g. the presence of alleles that influence the way in which cells metabolize dietary fats
5C: 5 Dietary Antioxidants & CVD

Learning outcomes:

• Understand the link between dietary antioxidants and the

risk of cardiovascular diseases
•We know that eating fruits and vegetables is good for us; one reason that has been proposed to explain this is
that these foods are high in chemicals called antioxidants
• Antioxidants include vitamins such as
• Vitamin A; found in orange vegetables such as carrots and sweet potato
• Vitamin C; found in citrus fruits
• Vitamin E; found in leafy vegetables, some nuts, and some oils

•Some research into antioxidants has been held up in support of the theory that antioxidants in the diet reduce
the risk of heart disease, but more recent data analysis has suggested that there is not enough evidence to
conclude this
• Some recent research even suggests that antioxidants could increase the risk of heart disease
Engage and explore:

1. How do antioxidants function in the body to potentially reduce the risk of CVD?

2. Read the case study on page 63 and draw the conclusion

The evidence for antioxidants

•We know that vitamin C is important for the formation of connective tissues in the body, so it is logical to
think that an increase in dietary vitamin C could help to reduce the damage to the artery endothelial
layer that leads to atherosclerosis
• Atherosclerosis is the process by which fatty plaques called atheroma's develop inside a damaged
arterial lining

•In a study involving 1605 men in Finland, 70 men had a heart attack between 1984 and 1992

• 13.2 % of the men with low vitamin C levels had a heart attack

• 3.8 % of the men with normal vitamin C levels had a heart attack

•Many concluded from this study that increasing vitamin C intake would reduce the risk of heart disease
Inconclusive evidence

•A large analysis of many studies on vitamin C and heart disease was carried out in 2016
• A study that analyses the results of many existing studies is known as a meta-analysis

•The 2016 study showed that there was no clear relationship between increased vitamin C intake and a
reduced risk of heart disease

•The study also suggested that taking antioxidant supplements could be harmful to circulatory system health

•This is an example of an area of study with conflicting evidence; it is essential that all evidence is taken into
account when drawing conclusions or deciding that evidence is still inconclusive
 Core Practical 2: Investigate the Vitamin C Content of Food & Drink

Investigating the Vitamin C Content of Food & Drink

•Vitamin C is found in green vegetables, fruits, and potatoes

•It is essential for a healthy diet

•The chemical name for vitamin C is ascorbic acid

• Ascorbic acid is a good reducing agent and therefore it is easily oxidized

•Methods for the detection of vitamin C involve titrating it against a solution of an oxidizing agent called DCPIP

• DCPIP is a blue dye that turns colorless in the presence of vitamin C

• Titration is a method of chemical analysis that involves determining the quantity of a substance present
by gradually adding another substance; in this case the concentration of vitamin C is determined by
gradual addition of a vitamin C solution to DCPIP
Apparatus Method
•Vitamin C solutions 1.Make up a series. e.g. six, of known vitamin C concentrations
•1% DCPIP solution • This can be done by serial dilution
•Distilled water 2.Use a measuring cylinder to measure out 1 cm3 of DCPIP solution into a test
•Range of fruit juices tube
•Measuring cylinder 3.Add one of the vitamin C solutions, drop by drop, to the DCPIP solution using a
•Pipette graduated pipette or burette
•Stop watch 4.Shake the tube for a set period of time using a stop watch
•Test tubes • It is important to keep the shaking time the same for each concentration;
this is a control variable
5.When the solution turns colorless record the volume, in number of drops, of
vitamin C solution added
6.Repeat steps 2-5 for the same concentration twice more and calculate an
average
7.Repeat steps 2-6 for each of the known concentrations
8.Results can be plotted as a line of best fit showing the average volume of
vitamin C needed to decolorize DCPIP against the concentration of vitamin C
• This is a calibration curve and can be used to find the concentration of
vitamin C in unknown samples such as fruit juices
Drops of vitamin C solution of known concentration can be added to DCPIP to
determine the volume required for the DCPIP to be decolorized
Risk assessment Results

•DCPIP is an irritant •The volume of vitamin C solution required to decolorize DCPIP

• Avoid contact with the skin should decrease as the concentration of the vitamin C
• Wear eye protection solution increases.

•The results of the experiment can be plotted on a graph of volume of

vitamin C needed to decolorize DCPIP against the concentration of
vitamin C

• The line of best fit for such a graph is known as a calibration

curve; unknown substances can be compared to it to gain
an estimate of their vitamin C concentration

•The calibration curve produced from this experiment can be used

to estimate the concentration of vitamin C in fruit juices
A graph of volume of vitamin C needed to decolorize DCPIP against vitamin C concentration can
be used as a calibration curve to estimate the vitamin C concentration of unknown substances
 1C: 6 USING THE EVIDENCE

Objectives:

understand how people use scientific knowledge about the effect of diet, including
obesity indicators, exercise and smoking to reduce their risk of coronary heart
disease
Diet

Some scientific studies have linked a diet high in saturated fats to an increased risk of CVD

• It is worth noting that there are other studies that are inconclusive on the link between dietary saturated
fat and CVD risk

Studies that investigate the connection between diet and CVD can be used to educate members of the public on
their consumption of certain foods

• Food labels now exist on most food packaging making consumers aware of what they are eating.

• Traffic light warning labels (Red = high, Orange = medium, Green = low) also exist on many food labels to
warn consumers of high levels of sugar, saturated fat, and salt.

• People are able to make informed choices about their diets

Obesity has been linked to an increase in CVD events.

•Healthcare professionals can use a number of measures to identify obesity in patients

• Waste-to-hip ratio is the circumference of the waist in cm divided by the circumference of the hips in cm
• For women the ratio should be less than 0.86
• For men the ratio should be less than 1.0

• BMI is a value derived from dividing an individual's mass in kg by the square of their height (m2)
• A BMI of less than 18.5 indicates that the person is underweight
• 18.5 - 24.9 is considered normal
• 25 - 29.9 is considered overweight
• A person with a BMI of 30 or higher is considered obese

Ø Obese individuals can make lifestyle choices to reduce their weight to a healthy range
Smoking

Ø Smoking has been linked to CVD by many research studies.

Ø The research has led to changes in the way cigarettes are advertised

• Health warnings now exist on all packets

• TV and media portray smoking as an unhealthy lifestyle choice

Ø Free materials, including prescriptions, are available to support individuals to stop smoking

Exercise

Ø Inactivity has been linked to increased risk of CVD

Ø There are many campaigns and initiatives to encourage all people to partake in more exercise

• Increased hours of physical education in schools

• Targeted encouragement at different groups of people, such as teenagers

 1C: 7 The benefits and risks of treatment

Objectives:
know the benefits and risks of treatments for cardiovascular disease (CVD)
(antihypertensives, statins, anticoagulants and platelet inhibitors)
While reducing the risk factors and lowering the risk of developing cardiovascular disease (CVD) is the
best option, CVD is still very common and treatment options are needed.

There are a number of different treatment options for cardiovascular disease, many of which involve
taking medication

Types of medication for the treatment of CVD include

• Antihypertensives
• Statins
• Anticoagulants
• Platelet inhibitors
Antihypertensives

Ø These drugs work by lowering blood pressure

• High blood pressure is also known as hypertension

Ø Lowering blood pressure reduces the risk of arterial endothelial damage and therefore reduces the risk of
atheroma's and thrombosis

Ø Beta blockers, vasodilators and diuretics act as antihypertensives

• Beta blockers prevent increases in heart rate by blocking the heart response to hormones like adrenaline.

• Sympathetic nerve inhibitors/ Vasodilators increase the diameter of the blood vessels
• ACE inhibitors are a type of drug that block the production of angiotensin, a hormone that causes
constriction of the blood vessels to rise blood pressure
• This keeps the arteries dilated, which lowers the blood pressure

• Diuretics reduce blood volume by decreasing the amount of sodium reabsorbed into the blood by the
kidneys, therefore decreasing the volume of water reabsorbed into the blood and increasing the volume of
urine produced.
Statins

Ø These drugs work by lowering blood cholesterol

• They block an enzyme in the liver which is needed to make cholesterol

Ø This lowers the LDL concentration in the blood therefore reducing the risk of atheroma formation
• LDLs are sometimes known as 'bad' cholesterol; at high levels they increase the risk of
atheroma's forming

Ø Statins also reduce inflammation in the arterial lining, which lowers the risk of atherosclerosis
Anticoagulants

Ø These drugs reduce blood clotting

• Blood clotting can be referred to as blood coagulation

• Warfarin is an anticoagulant that decreases the level of prothrombin in the bloodstream

Ø Reduced formation of blood clots decreases the likelihood of thrombosis and therefore reduces
the risk of blood vessels being blocked by blood clots
Platelet inhibitors

Ø These are also substances which reduce blood clotting

• Platelet inhibitors are a type of anticoagulant

• Aspirin and clopidogrel are the most commonly used examples of these drugs

Ø They prevent the clumping together of platelets, so preventing the formation of blood clots