Education And Debate

Cardiovascular risk factors in Croatia: struggling to provide the evidence for developing policy recommendations

BMJ 2005; 331 doi: (Published 21 July 2005) Cite this as: BMJ 2005;331:208
  1. Josipa Kern, professor of medical informatics (jkern{at},
  2. Marija Strnad, associate professor of epidemiology2,
  3. Tanja Coric, epidemiologist, Social Medicine Service2,
  4. Silvije Vuletic, professor emeritus3
  1. 1 Andrija Stampar School of Public Health, Zagreb University School of Medicine, Rockefellerova 4, 10000 Zagreb, Croatia
  2. 2 Croatian Public Health Institute, Rockefellerova 7, 10000 Zagreb
  3. 3 Zagreb University School of Medicine, Zagreb
  1. Correspondence to: J Kern

    Reliable epidemiological data on cardiovascular risk factors in Croatia have been lacking. This new study identifies targets for interventions


    Cardiovascular disease is the major cause of death in most European transitional countries.1 Among these countries, standardised mortality from cardiovascular disease is highest in Hungary (508 per 100 000 population) and Croatia (500/100 000) and lowest in Slovenia (295/100 000) and central European countries (238/100 000). In Croatia, cardiovascular disease is the leading cause of death and accounts for more than half the overall mortality.1 Furthermore, cardiovascular mortality has been constantly rising since the 1970s.

    Tackling the problem

    Until recently, no reliable epidemiological data were available on the prevalence of cardiovascular risk factors in the Croatian population. The existing studies only comprised small unrepresentative samples and provided conflicting results. Hence, there was no evidence base for developing policy on reducing the burden of cardiovascular disease in the future and recommending interventions for people with cardiovascular risk factors.2 3

    In collaboration with the Canadian Society for International Health, we conducted the Croatian adult health survey in the summer of 2003 among citizens aged 18 and older. After we stratified the country by region (as defined by the Croatian Central Bureau of Statistics), the sample comprised 10 766 randomly selected households; 9070 individuals agreed to participate (overall response rate 84.2%). This was the first representative population survey to be conducted in Croatia.

    Embedded Image

    Traditional Croatian food: consume sparingly

    Croatia is a sickle shaped country with two distinct geographical regions that traditionally differ in many aspects, including diet and general lifestyle. The people in the “continental” part of the country bear similarities with their northern neighbours in Hungary, whereas those in the coastal part beside the Adriatic Sea traditionally share the lifestyle of Mediterranean people.46 Zagreb, the capital, is in the northern part and is home to about a quarter of the total population (about four million) of Croatia. We analysed our data separately for three areas: continental (eastern, northern and central regions); Adriatic (south and west); and the city of Zagreb.7

    The survey enabled us to estimate the prevalence of six main cardiovascular risk factors: obesity, high blood pressure, smoking, physical inactivity, high alcohol consumption, and inadequate nutrition. We defined obesity as body mass index of 30 or higher, and the cut-off point for high blood pressure was 130/85 mm Hg. Current daily smokers and those who quit less than 10 years ago were classified as smokers. Those who fulfilled at least three of the following criteria were counted as physically inactive: driving to work, working in white collar occupations, taking less than two 30-minute sessions of exercise weekly in their leisure time, and having someone constantly advising them on the need for more physical activity. High alcohol consumption was defined as having a binge of heavy drinking at least once a week, drinking alcohol daily, or having someone constantly advising them on the need to cut down on alcohol consumption. Finally, those who fulfilled at least three of the following criteria were classified as having an inadequate diet: regularly eating food prepared with animal fat, regular consumption of full-fat (at least 3.2%) milk and milk products, low consumption of fruits, eating smoked meat at least twice a week, and adding salt to food before tasting.

    Ranking the prevalence of risk factors and summarising the ranks showed that the patterns differed between the areas and by sex (table) (further data available from authors). In men, the most prominent risk factor was high blood pressure, followed by smoking, physical inactivity, high alcohol consumption, inadequate nutrition, and obesity. The hierarchy was somewhat different in women, with high blood pressure again being the most prevalent risk factor, but followed by physical inactivity, obesity, smoking, inadequate nutrition, and high alcohol consumption. The prevalence of hypertension in all regions exceeded 50% in men and 44% in women.

    Percentage (95% confidence intervals) of the Croatian population aged 18 and over with cardiovascular risk factors by geographic area

    View this table:

    Our results primarily demonstrated the heterogeneity of the country with respect to the prevalence of cardiovascular risk factors. In particular, people in the southern region had an extremely low prevalence of inadequate nutrition. Zagreb showed the typical characteristics of urban areas, with physical inactivity being the most prevalent risk factor—almost double the rate in other regions. The east led in unhealthy nutrition and the south in high alcohol consumption.

    Summary points

    Cardiovascular mortality is the leading public health problem in Croatia

    Prevalence of cardiovascular risk factors is generally high, but the hierarchy varies between regions and by sex

    The prevalence of hypertension in all regions exceeds 50% in men and 44% in women

    Public health programmes should be targeted at reducing the prevalence of hypertension, obesity, smoking, and alcohol drinking, and promoting physical activity and healthy diet

    Local governments should adjust the national recommendations to fit the specifics of their region

    Interestingly, our survey showed that obesity was one of the most common risk factors in women but the least prevalent in men. Further differences among sexes included smoking, inadequate nutrition, and alcohol in particular, which were consistently less prevalent among women than among men.

    Policy recommendations and implementation

    Despite a national cardiovascular disease prevention programme in Croatia, the prevalence of cardiovascular diseases has risen consistently since the 1970s and the evidence base for the programme was poor. The Ministry of Health has now tackled the problem by commissioning the first nationally representative survey focusing on cardiovascular risk factors. The ministry is now adapting the healthcare intervention programme according to the results of the survey. The results will also play a crucial role in determining the conditions of contracts for compulsory health insurance.

    The new revised intervention programme provides national guidance for prevention of and health promotion in cardiovascular health. It emphasises the need for a holistic approach to each patient and the general need to promote healthier lifestyles—reducing tobacco use and alcohol consumption and promoting healthy nutrition and physical activities. We recommend that general practitioners and public health workers, who will be expected to implement the programme, bear in mind the heterogeneity of the country with respect to cardiovascular risk factors. The evidence calls for decentralised implementation through alerting and mobilising local governments to adjust their programmes and choose priorities for health care. This simple cross sectional survey was a big and costly task for Croatia's healthcare system and represents an important local advance in monitoring the population's health. Its results must be fully used to improve the population's health.


    • Contributors and sources JK conceived and designed the study, analysed and interpreted the data, and drafted and revised the article. MS conceived and designed the study, interpreted the data, and revised the article. TC revised the article, SV conceived and designed the study, analysed and interpreted the data, and drafted and revised the article. JK, MS, and TC did the literature search. JK is the guarantor.

    • Funding Croatian Ministry of Health, Health System Project IBRD (loan 4513-0 HR).

    • Competing interests None declared.

    • Ethical approval Not required.


    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.
    6. 6.
    7. 7.
    View Abstract