INTRODUCTION:

According to World Health Organization (WHO)¹, deaths caused by cardiovascular diseases (CVD) represent 63% of the total number of annual death, while from this number, 80% of the CVD deaths is due to coronary heart disease (CHD) and stroke¹. There are many studies highlighting the associations of short stature with increased risk of CHD^2-9. Based on these studies, taller people will have a more desirable disease risk profile in their adulthood as compared to shorter people who tend to have an adverse disease risk profile. Moreover, gender factor will not alter this association which means a short person of both male and female will have an equal increased risk of developing CHD compared to a taller person^{3, 4}.

In a study on more than 35,000 twin pairs, individuals who died from CHD were on average shorter than their monozygotic pairs, while the height difference was not apparent in dizygotic pairs suggesting that other components than genetic elements are responsible for the association⁶.

Blood total cholesterol (TC) is one of the early markers used to determine CHD risk. High blood TC had been associated with poor disease prognosis such as in ischaemic stroke^10-12, CHD¹², cerebral infarction¹¹, metabolic syndrome¹³, Alzheimer’s disease¹⁴ and male colon cancer¹⁵. Since early detection and management are the best preventive measures for CHD, the measurement of blood TC is of high importance in order to screen for the disease risk. Measuring blood TC is cheaper, less-invasive and more feasible than trying to get the complete lipid profile which is costly, invasive and requires advanced instrument in the medical laboratory. This self-test can be done at home at least once every five years for an individual above 20 and every 12 months for individual under cholesterol lowering treatment¹⁶. However, this method is only meant as a screening tool and any deviations from the normal cholesterol reading should be further clarified with complete lab-based lipid profile and physician consultation.

Therefore the main aim of this study was to find the correlation of height with blood TC level among young adults, in relation to the inverse association of height with CHD risk. The potential use of the two parameters in combination as an indicator of CHD risk in adulthood is also discussed. As comparisons, this study also tried to identify the correlation of other anthropometric indices such as weight and body mass index (BMI) with blood TC level. The prevalence of hypercholesterolemia among young adults as overall and in different genders were also studied.

MATERIALS AND METHODS:

Subjects and sampling method:

Convenience sampling method was used. 331 individuals (124 males, 207 females) aged 18 to 28 who were invited to participate in a health screening programme were screened. Written informed consent form was obtained.

Anthropometric Measurements:

Height and weight were measured in light clothing with shoes removed. Height was measured using Wall-Mounted Measuring Tape in centimeter (cm) and weight was measured using calibrated weighing scale to the nearest kilogram. BMI was calculated as weight in kilograms divided by height in meters squared.

Blood Total cholesterol test:

A fasting blood TC was measured using cholesterol meter from Accoutered® Plus System by Roche. A very small volume of blood was drawn by finger prick and applied on the Accoutered cholesterol strip and inserted into the Accoutered ® plus meter to get the cholesterol reading.

Statistical analysis:

Data analysis was performed using SPSS version 17.1. Normality test was done before the data was subjected to further analysis. The Student’s t-test and Mann-Whitney U test were used to compare the means for data that were normally and non-normally distributed respectively. Pearson correlation coefficient was used to study the association of data which both were normally distributed and the Spearman’s correlation was used when at least one variable displayed non-normal distribution. A value of p < 0.05 was considered statistically significant.

RESULTS AND DISCUSSION:

Association of height with blood total cholesterol:

Table 1 indicates the means of height, weight, BMI and blood total cholesterol in male and female subjects. The mean of blood TC was higher in female compared to the male subjects (Table 1). Therefore our result supports other’s finding on female bias in blood total cholesterol level¹¹. Non-parametric Spearman correlation tests were conducted to study the correlation of each anthropometric parameter i.e. height, weight and body mass index (BMI) with blood TC. Weight and BMI did not demonstrate significant associations with blood TC. Whereas when the data on height of both men and women were analyzed together, significant (p<0.05) inverse association with blood TC was obtained (Table 2). This result indicates that shorter stature is associated with high blood TC level and vice versa. However, when the data was analyzed separately in men and women, no significant association was found.

Table 1: Anthropometric indices and blood total cholesterol levels between genders and the overall subject group

Anthropometric indices	Male	Female	Total
Age	20.44±1.83	20.18±0.97	20.28±1.36
Height	168.50±6.80	157.60±7.53	161.68±8.98
Weight	68.41±13.68	55.57±13.05	60.38±14.66
BMI	24.03±4.24	22.27±4.40	22.89±4.44
Total cholesterol	4.83±0.72	5.1±0.75	5.0±0.75

*The values are the mean with standard deviation.

Table 2: The correlation study between the three anthropometric indices with blood total cholesterol level

Correlation study	Group	Correlation coefficient (r)	p value
Height vs. Total Cholesterol	Male	- 0.064	0.48
	Female	- 0.053	0.45
	Male + Female	- 0.173**	0.02**
Weight vs. Total Cholesterol	Male	0.010	0.91
	Female	- 0.007	0.92
	Male + Female	- 0.104	0.06
BMI vs. Total Cholesterol	Male	- 0.006	0.95
	Female	- 0.007	0.92
	Male + Female	- 0.049	0.38

**This shows significant correlation

Several studies have demonstrated the inverse associations of height with CHD risk and mortality^3-7. A follow-up studies involving one million subjects on the association of adult height with fatal and non-fatal cardiovascular diseases, found a significant inverse relationship between height and deaths caused by CHD, stroke, cardiac failure, stomach and oral cancers, COPD, psychology disorder and hepatic disease. Another group also found inverse association between height and risk of CHD, stroke, CVD and cancer and total mortality^2,5. The inverse association of height with CHD risk has been attributed to many factors including childhood nutrition, socioeconomic status; low birth weight resulted from poor gestational nutrition and maternal smoking, maternal infection during pregnancy and existing illness and repeated infections during infancy and childhood^{3, 5-8, 17-20}.

Therefore, our data is in line with the other research groups which found similar inverse associations between height and CHD risk independent of gender-specific effect^{3-5, 20, 21}. This either reflects a true insignificance between the two genders or simply a result of the small sample size used in this study; however the consistency of our finding with others excludes the latter possibility. This finding hence supports Nelson et al. (2015)⁴ that the inverse association of height with risk of CHD is partly explained by the association of short stature with adverse lipid profile. The previous research finding that body fat percentage was higher in short compared to taller individuals¹⁹also justifies this finding. This becomes more significant when studies found height to be also negatively correlated with blood TC, low-density lipoprotein (LDL) and triglycerides, but positively correlated to HDL²². Low HDL cholesterol in fact has been implicated as a profound risk factor for mortality from CHD and stroke²³. Besides, previous findings also found positive correlation between high blood TC with increased risk of death resulted from CHD¹² and ischaemic stroke^{11, 12}. Particularly ischaemic stroke, the risk is increased with increased level of TC, which resulted from atherosclerotic progression²⁴.

As height has been used as an indicator of childhood nutritional status, the inverse association of height with many diseases is attributable to the fact that taller people are better nourished and having a healthier lifestyle as compared to people with short stature^{3, 7, 17, 20}. Poor nutrition during childhood had been demonstrated to be positively correlated with short stature and poor health outcome in adulthood^{7, 8,
17, 19}. A study on childhood (3-5 years old) nutrition had shown that a bad eating habit among these children was associated with increased blood non-high density lipoprotein (HDL) cholesterol level²⁵. Significant inverse association between height and CHD risk as well as CHD mortality, leading to the discussion of the national policies of childhood nutrition^{2,
5, 6}. This is of significant importance especially when research found that blood TC was higher in children having the risk for CVD based on their family history²⁶.

The familial genetic clustering between body height and blood cholesterol might also explain the inverse association of height with CHD risk^3,22. A study done on 180 single nucleotide polymorphisms (SNPs) that were associated with variation in height, found the associations of these SNP variants with LDL and triglyceride levels which followed their association trend with CHD. An increase in the number of height-related alleles was found to decrease the risk of CHD^3,4. These SNP variants were also found to be associated with growth hormones involved in atherosclerotic progression such as BMP, TGF-β, STAT and IGF-I⁴. Therefore a pleiotropic effect might have contributed to the associations of SNPs with these phenotypic traits. A genome wide study on the interaction of a genetic loci with a disease risk factor highlighted a SNP locus rs6448771 that significantly modified the interaction between waist-to-hip ratio (WHR) with blood TC, but not WHR or blood TC alone²⁷. This gives an idea that there is a complex biological mechanism involving the height-determining alleles that control both height and atherosclerotic progression resulting in the pathogenesis of CHD.

Besides that, taller people are associated with larger coronary artery and hence the chances for the same plaque burden to occupy the artery and being accelerated to atherosclerosis are lower compared to shorter people^4,5. Women are also associated with smaller blood vessel than men, regardless of height and body size, that predispose them to accelerated plaque burden. Therefore a female with shorter stature has higher risk of developing CHD⁴. This is in line with our finding that the mean of blood TC was significantly higher in female than in male (p<0.001). In a study involving 156,892 subjects, Suzuki et al. (2011)¹¹ also found higher mean of total cholesterol level in female compared to the male subjects.

Association of body weight and BMI with blood total cholesterol:

Increased weight has been associated with increased risk of hypercholesterolemia. Study found that an increase of ≥2.4 of BMI would increase the risk of developing hypercholesterolemia as much as 60% in male and the percentage was doubled in female²⁸. However, our study did not find a significant correlation between weight and level of blood TC (Table 2). Similarly, we did not find significant correlation between BMI and level of blood TC. This finding is in accordance with the other study in which BMI did not serve as a good marker for lipid and lipoprotein profiles²⁹. The use of BMI as a marker for determining CVD risk has long been replaced with better predictors such as waist-to-height ratio and waist circumference²⁹. The application of BMI in determining CVD risk factor is limited because it does not measure fat distribution in the body and does not discriminate between central and peripheral adiposity, whereas risk of CVD is associated with increased central adiposity which is highly insulin-resistant^19,30. Other reliable anthropometric parameters are now being used to determine CVD risk such as the waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) among which WHtR serves as the best indicator in both men and women^19,30-32.

Prevalence of high blood total cholesterol among young adults:

High blood TC or hypercholesterolemia is defined as blood TC ≥ 200 mg/dL (5.2 mmol/L), according to the National Institute of Health (NIH), United States. Hence, blood total cholesterol of ≥ 5.2 mmol/L (200 mg/dL) was considered high in this study (Table 3, Figure 1). The prevalence of high blood TC was found to be higher in female (0.44) than in male (0.26). Our finding coincided with others^{12, 19, 33}which also found higher prevalence of high blood TC in female. The frequency of overall high blood TC level in this study was 0.37, which is almost similar to the prevalence of high blood TC in the Iranian adult population (0.36) and in the Malaysian population (0.35) based on the National Health and Morbidity Survey in 2011^19,34. Studies on sub-populations in Malaysia on the other hand found the prevalence of hypercholesterolemia of 0.40 in Selangor and 0.31 in Kelantan^33,35. Our finding also is in accordance with the finding by Amiri et al. (2014)³⁶ which found the prevalence of high blood TC of 0.38 among the residents of urban community in Malaysia aged 18 to 29 years old. Most importantly the prevalence was increased in adult of increasing age. This indicates that the finding of this study is at least limited to the young adult group i.e. 18 to 28 years old.

Table 3: The prevalence of high blood TC level between genders and in the overall subject group

Gender	No.	High TC	Frequency
Male	124	32	0.26
Female	207	91	0.44
Total	331	123	0.37

Figure 1: The prevalence of high blood TC level between genders and in the overall subject group

CONCLUSION:

Height is found to be inversely associated with the risk of CHD in many population studies. Both genetics and environmental factors are found to contribute to this relationship. Familial clustering of height-associated alleles with lipid profile by means of pleiotropic effect, gestational, infancy and childhood nutrition, socioeconomic position, exposure to incidences of infection and inflammation and the diameter of artery are among the plausible mechanisms for the associations. High blood total cholesterol is an established marker for CVD especially CHD and ischaemic stroke. Since we found significant inverse association of height with blood TC, we therefore propose the use of height in combination with blood TC data as a means of determining CHD risk among the young adult group. Nevertheless, further research is warranted to delineate the overall influence of height together with blood TC on CHD risk determination.

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Received on 11.07.2017 Modified on 24.08.2017

Research J. Pharm. and Tech. 2018; 11(3): 836-840.

DOI: 10.5958/0974-360X.2018.00155.5