Factors Predicting High Estimated 10-Year Stroke Risk: Thai

Epidemiologic Stroke Study

Suchat Hanchaiphiboolkul, MD,* Pimchanok Puthkhao, MSc,*
Somchai Towanabut, MD,* Tasanee Tantirittisak, MD,*
Khwanrat Wangphonphatthanasiri, MD,* Thanes Termglinchan, MD,*
Samart Nidhinandana, MD, Nijasri Charnnarong Suwanwela, MD,
and Niphon Poungvarin, MD, FRCPx

Background: The purpose of the study was to determine the factors predicting high
estimated 10-year stroke risk based on a risk score, and among the risk factors
comprising the risk score, which factors had a greater impact on the estimated
risk. Methods: Thai Epidemiologic Stroke study was a community-based cohort
study, which recruited participants from the general population from 5 regions of
Thailand. Cross-sectional baseline data of 16,611 participants aged 45-69 years
who had no history of stroke were included in this analysis. Multiple logistic regression analysis was used to identify the predictors of high estimated 10-year stroke
risk based on the risk score of the Japan Public Health Center Study, which estimated
the projected 10-year risk of incident stroke. Results: Educational level, low personal
income, occupation, geographic area, alcohol consumption, and hypercholesterolemia were significantly associated with high estimated 10-year stroke risk. Among
these factors, unemployed/house work class had the highest odds ratio (OR, 3.75;
95% confidence interval [CI], 2.47-5.69) followed by illiterate class (OR, 2.30; 95%
CI, 1.44-3.66). Among risk factors comprising the risk score, the greatest impact as
a stroke risk factor corresponded to age, followed by male sex, diabetes mellitus, systolic blood pressure, and current smoking. Conclusions: Socioeconomic status, in
particular, unemployed/house work and illiterate class, might be good proxy to
identify the individuals at higher risk of stroke. The most powerful risk factors
were older age, male sex, diabetes mellitus, systolic blood pressure, and current
smoking. Key Words: Thailandepidemiologystrokerisk factors10-year
stroke risk.
2014 by National Stroke Association

From the *Prasat Neurological Institute, Department of Medical

Services, Ministry of Public Health, Bangkok; Division of Neurology,
Department of Medicine, Phramongkutklao Hospital, Bangkok;
Division of Neurology, Department of Medicine, Chulalongkorn
University, Bangkok; and xDivision of Neurology, Department of
Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Received January 16, 2014; accepted January 26, 2014.
This study was supported by grants from the Prasat Neurological
Institute, the National Neurological Institute of Thailand, and the
Department of Medical Services, Ministry of Public Health, Thailand.

Address correspondence to Suchat Hanchaiphiboolkul, MD, Prasat

Neurological Institute, Department of Medical Services, Ministry of
Public health, 312 Rajavithi Road, Bangkok 10400, Thailand. E-mail:
suchathanc@yahoo.com.
1052-3057/$ - see front matter
2014 by National Stroke Association
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.01.025

Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2014: pp 1-6

S. HANCHAIPHIBOOLKUL ET AL.

Introduction
Stroke is the second most common cause of death after
myocardial infarction and is a leading cause of acquired
disability worldwide.1 More than 85% of fatal stroke
occur in low- and middle-income countries,2 with a
greater than 100% increase in stroke incidence over the
past 4 decades.3 Without intervention, the number of
global deaths is projected to rise to 6.5 million in 2015
and 7.8 million in 2030.2 Despite the advent of treatment
of selected patients with stroke, the best approach to
reduce the burden of stroke remains prevention by modification or control of stroke risk factors.2,4 However,
reliable data on stroke risk factors in developing
countries including Thailand are lacking.5,6 In Thailand,
stroke is a major health problem and the leading cause
of death for both males and females.7 Although the data
on stroke incidence in Thailand is not currently available,
a study in 2011 showed that the stroke prevalence in
Thailand is 1.88% in people aged 45-80 years,8 which
has increased from previous study in the elderly (1.12%)
in 1998.9
For primary stroke prevention, it seems intuitively
appropriate to identify specific risk-reducing interventions for those individuals who have not yet had symptoms of vascular disease, but are at highest risk.10
The American Heart Association recommends that all
asymptomatic adults receive a global cardiovascular
risk screening.11 Similarly, the United Kingdom National
Screening Committee recommends cardiovascular risk
screening for all adults aged 40-74 years who are free of
cardiovascular disease and known cardiovascular risks.12
However, these strategies particularly might not be practical in the context of developing countries, which often
have limited resources. Therefore, the identification of
people who have factors predicting high estimated 10year stroke risk is required, and further risk screening,
evaluation, and treatment, when appropriate, might be
warranted. In the present study, individuals 10-year
stroke risk was estimated by using a risk score developed
from the Japan Public Health Center Study13, which estimated the projected 10-year risk of incident stroke.
Furthermore, each risk factor comprising the risk score
may have a different impact on the estimated risk, so if
we understand more on this relationship, the management of stroke prevention could be improved.
The purpose of the present study was to determine the
factors predicting high estimated 10-year stroke risk, and
among the risk factors comprising the risk score, which
factors had a greater impact on the estimated risk.

Methods
Participants
The Thai Epidemiologic Stroke Study is a communitybased cohort study, an ongoing process to investigate the

relationship between various risk factors, lifestyles, and

stroke in Thailand. A general population cohort aged 4580 years (n 5 19,997) was enrolled on the voluntary basis
from the following 5 geographic regions of the country:
Bangkok (capital city), Chiang Mai province (northern region), Khon Kaen province (northeastern region), Chachoengsao province (central region), and Nakhon Si
Thammarat province (southern region). Although our
study sample was not established by random sampling
but it covers all major demographic strata of the Thai general population aged 45-80 years.8 In the present study,
baseline survey data were studied as cross-sectional analyses. We limited our analyses to participants aged 4569 years (n 5 16,611) and excluded those with a history
of stroke (n 5 292) because the risk score13 that we used
was developed from participants aged 40-69 years, who
were free of stroke at baseline. The study was approved
by the Ethical Review Committee for Research in Human
Subjects, Ministry of Public Health, Thailand. Signed
informed consent was obtained from all participants.

Baseline Survey
Baseline health survey data were collected at a community place during 2004 and 2006. Measurement of blood
pressure and anthropometric data, collection of blood sample after overnight fast, and face-to-face interview assessing demographic information and medical history were
performed under standard operating procedures by a
well-trained staff. The amount of alcohol consumption
was estimated using responses to the question items on frequency, average daily amount, and type of alcohoic beverages. On the basis of stroke screening questionnaire,
participants who were suspected to have a stroke were interviewed and examined by board-certified neurologists
for determining stroke status. The details of stroke
screening questionnaire and the method for verification
of stroke status have been described in our previous publication.8 Blood pressure was measured in a sitting position
with the use of an automated blood pressure device (Omron HEM-907; Omron Healthcare Singapore Pte Ltd,
Singapore) after participants had rested at least for 5 minutes. Height and weight were measured in light clothes
without shoes to the nearest .1 cm and .1 kg, respectively.
Digital weight measurement machine (TANITA BWB800; TANITA Corporation, Japan) was used. Venous blood
samples were obtained after a 12-hour overnight fast. Analyses for glucose and lipid profile were performed at the
Division of Clinical Chemistry, Faculty of Medicine Ramathibodi Hospital, which was certified by the Centers for
Disease Control, USANational Heart, Lung and Blood
Institute Lipid Standardization Program.

Definitions
Education, personal income, and occupation were used
as indicators of socioeconomic status (SES). Education

FACTORS PREDICTED HIGH ESTIMATED STROKE RISK

was classified as illiterate, primary, secondary, and university levels. Personal income was categorized using
monthly income cutoffs at less than 5000 Thai baht as
low personal income (35 Thai baht z 1 US dollar in
2009 and 32 Thai baht z 1 US dollar in 2013). Occupation
was classified as follows: nonmanual, manual class, agricultural class, and unemployed/house work class. Nonsmokers were those who had never smoked at all or
had smoked less than 100 cigarettes in their lifetime. Current smoker was defined as having smoked 100 or more
cigarettes in a lifetime and smokes cigarettes currently.
Participants who smoked 100 or more cigarettes in their
lifetime but currently do not smoke at all were defined
as ex-smokers. Hypertension was defined as blood pressure of 140/90 mm Hg or more or self-reported use of
antihypertensive medication. Fasting plasma glucose of
7.0 mmol/L (126 mg/dL) or more or history of treatment
for diabetes was defined as diabetes. Hypercholesterolemia was defined as fasting total cholesterol of
5.2 mmol/L (200 mg/dL) or more or self-reported use
of medication for hypercholesterolemia.
Assessment of 10-year stroke risk of each individual
was based on the risk score of the Japan Public Health
Center Study13 (n 5 15,672), which was developed to predict 10-year risk of onset of stroke (hemorrhagic and
ischemic stroke). The risk score was developed from the
following variables: age, sex, current smoking, body
mass index, blood pressure, antihypertensive medication,
and diabetes mellitus. The 10-year stroke risk of each individual was reclassified as low (,10%) and high risk
($10%). This classification is arbitrary, as it has not been
defined what is low or high 10-year risk for stroke.

variables, which included in the risk score, were obtained

by multiplying each unstandardized beta coefficient by
the standard deviation of the predictor to which the coefficient refers.14
All probability values were 2 sided, and the level of significance was set at a value of P less than .05. All statistical
analyses were performed using SPSS for Windows
version 16.0 (IBM, Armonk, NY)

Statistical Analysis
Continuous variables were presented as the mean and
standard deviation. Categorical variables were described
as percentages. The differences in baseline characteristics
between men and women were analyzed using an independent sample t test for continuous variables and the
chi-square test for categorical variables.
Multiple logistic regression analyses were used to identify the predictors of high estimated 10-year stroke risk.
The independent or predictor variables included in
model 1 were educational level, low personal income,
occupation, geographic area, alcohol consumption. and
hypercholesterolemia. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to illustrate the association.
To compare the impact of each risk comprising the risk
score on high estimated 10-year stroke risk, model 2 was
fitted by including variables as model 1 plus variables,
which included in the risk score, that is, age, sex, current
smoking, body mass index, systolic blood pressure, diastolic blood pressure, antihypertensive treatment and diabetes mellitus. Standardized beta coefficients of the

Results
Table 1 summarizes the characteristics of the study
sample. A total of 16,611 participants (5406 men, 11,205
women) who were free of stroke, with mean age of
56.3 years (standard deviation, 6.9 years) and range of
45-69 years, were included in the study. The average
age was 56.7 years for men and 56.0 years for women
(P , .001). Educational level, low personal income, and
occupation were of significant difference between men
and women (P , .001). Higher prevalence of agricultural
class was found in men, whereas women have higher
prevalence of illiterate, low personal income, unemployed/house work and living in Bangkok (capital city).
Men showed significantly higher prevalence of smoking
and alcohol consumption and significantly higher values
for diastolic blood pressure, whereas women had higher
values for body mass index and higher prevalence of hypertension, antihypertensive treatment, and hypercholesterolemia. Prevalence of high estimated 10-year stroke
risk was 9.2% (19.0% in men, 4.4% in women, P , .001).
In multiple logistic regression analysis (model 1),
educational level (P , .001), low personal income
(P 5 .012), occupation (P , .001), geographic area
(P , .001), alcohol consumption (P 5 .004), and hypercholesterolemia (P 5 .002) were significantly associated with
high estimated 10-year stroke risk. Among these factors,
unemployed/house work class had the highest OR
(3.75; 95% CI, 2.47-5.69) followed by illiterate class (OR,
2.30; 95% CI, 1.44-3.66) (Table 2).
To evaluate the specific impact of each variable
included in the risk score on the high estimated 10-year
stroke risk in the study population, a multiple logistic
model (model 2) was constructed including the variables
as model 1 plus variables, which included in the risk
score, that is, age, sex, current smoking, body mass index,
systolic blood pressure, diastolic blood pressure, antihypertensive treatment, and diabetes mellitus. In the resulting model, the greatest impact as stroke risk factor
corresponded to age, followed by male sex, diabetes mellitus, systolic blood pressure, and current smoking
(Table 3).

Discussion
In this community-based cross-sectional study performed in Thai general population (n 5 16,611) aged

S. HANCHAIPHIBOOLKUL ET AL.

Table 1. The characteristics of a study sample

Variable

Total (n 5 16,611)

Men (n 5 5406)

Women (n 5 11,205)

P value

Age (y; mean, SD)

Education level
Illiterate (%)
Primary (%)
Secondary (%)
University (%)
Low personal income (,5000 Thai baht*/mo; %)
Occupation
Nonmanual class (%)
Manual class (%)
Agricultural class (%)
Unemployed/house work (%)
Geographic area
Bangkok (%)
Central region (%)
Southern region (%)
Northern region (%)
Northeastern region (%)
Body mass index (kg/m2; mean, SD)
Smoking status
Never (%)
Ex-smoker (%)
Current (%)
Alcohol consumption (g/wk; %)
,150
150 to ,300
$300
Hypertension (%)
Systolic blood pressure (mm Hg; mean, SD)
Diastolic blood pressure (mm Hg; mean, SD)
Antihypertensive treatment (%)
Diabetes mellitus (%)
Hypercholesterolemia (%)
High estimated 10-y risk of strokey (%)

56.3, 6.9

56.7, 6.8

56.0, 6.8

,.001
,.001

1.9
77.3
12.9
7.9
67.4

.8
72.5
19.2
7.5
58.4

2.5
79.6
9.8
8.0
71.7

6.4
38.0
32.6
23.0

7.0
36.8
43.5
12.7

6.1
38.6
27.3
28.0

10.8
24.9
12.1
21.5
30.7
24.7, 4.2

7.6
22.1
13.9
25.0
31.4
23.5, 3.8

12.4
26.2
11.2
19.8
30.3
25.3, 4.2

72.2
13.8
14.0

26.1
36.0
37.9

94.3
3.2
2.5

96.1
2.2
1.7
39.6
135.5, 21.9
76.2, 12.4
17.9
15.7
66.2
9.2

89.3
5.9
4.8
37.7
135.5, 21.8
77.0, 13.0
14.7
15.1
56.1
19.0

99.3
.4
.2
40.6
135.5, 21.9
75.9, 12.0
19.5
16.0
71.1
4.4

,.001
,.001

,.001

,.001
,.001

,.001

,.001
.919
,.001
,.001
.105
,.001
,.001

*35 Thai baht z 1 US dollar in 2009 and 32 Thai baht z 1 US dollar in 2013.
yDefined as estimated 10-years risk of stroke of 10% or more.

45-69 years, enrolled from 5 geographic regions of

Thailand, the prevalence of high estimated 10-year stroke
risk ($10%) was 9.2% (19.0% in men, 4.4% in women). In
multiple logistic regression analysis, educational level,
low personal income, occupation, geographic area,
alcohol consumption, and hypercholesterolemia were
significantly associated with high estimated 10-year
stroke risk (Table 2). Among these associated factors, unemployed/house work (OR, 3.75; 95% CI, 2.47-5.69) and
illiterate (OR, 2.30; 95% CI, 1.44-3.66) had the higher
odds ratio. When risk factors comprising the risk score
were added to the model, we found that age, followed
by male sex, diabetes mellitus, systolic blood pressure,
and current smoking had the greatest impact on the
high estimated 10-year stroke risk ($10%) (Table 3).
Knowledge of existing disparities in stroke risk is
important for effective stroke prevention and manage-

ment.15 SES is an individual s position relative to others

based on income, education, and occupation.16 Our study
showed that low SES was a strong predictor of high estimated 10-year stroke risk. These findings were consistent
with the previous meta-analysis of 17 studies, which
demonstrated an increased incidence of stroke in those
of lower SES (pooled hazard ratio, 1.67; 95% CI, 1.461.91).16 The associations between lower SES and the
incidence of stroke have generally been demonstrated
across stroke subtypes.17,18 However, some studies have
demonstrated nonsignificant or weaker associations
with hemorrhagic stroke.19-21 It is not certain what
causes the link between lower SES and stroke.22 However,
classic vascular risk factors partly explain the increased
risk of stroke among lower SES groups.16 A greater
burden of vascular risk factors in lower SES groups has
been shown in some studies19,21,23; however, the results

FACTORS PREDICTED HIGH ESTIMATED STROKE RISK

Table 2. Factors predicting high estimated 10-years risk of

stroke ($10%) in multiple logistic regression analysis
Variable
Education level
Illiterate
Primary
Secondary
University
Low personal income
(,5000 Thai baht*/mo)
Occupation
Nonmanual class
Manual class
Agricultural class
Unemployed/house work
Geographic area
Southern region
Northern region
Bangkok
Northeastern region
Central region
Alcohol consumption (g/wk)
,150
150 to ,300
$300
Hypercholesterolemia

OR

95% CI

2.30
1.44
2.00
1.00
1.20

1.44-3.66
1.02-2.03
1.42-2.84

1.04-1.39

Geographic variation in stroke incidence has been

observed in some regions such as the United States25
and China.26 The present study also demonstrated that
a geographic area was associated with high estimated
10-year stroke risk with the highest OR (1.52; 95% CI,
1.24-1.87) in northeastern region. Differences in risk factors may explain this association.
A meta-analysis based on 35 observational studies
demonstrates that heavy alcohol consumption increases
the relative risk of stroke, whereas light or moderate
alcohol consumption may be protective against total
and ischemic stroke.27 Our study found that alcoholic
consumption was a significant predictor of high estimated 10-year stroke risk. Most but not all epidemiologic
studies find an association between higher cholesterol
levels and increased risk of ischemic stroke, and also between lower cholesterol levels and increased risk of hemorrhagic stroke.28 In the present study, the 10-year stroke
risk was estimated by risk score, which predicts stroke
including ischemic and hemorrhagic stroke, and it was
found that hypercholesterolemia was a significant predictor of high 10-year stroke risk.
In this study, among factors comprising the risk score,
age, male sex, diabetes mellitus, systolic blood pressure,
and current smoking were factors of a greater impact on
stroke risk estimation in our population. Although older
age and male sex are nonmodifiable, people in these
groups could get benefit from rigorous prevention or
treatment of other modifiable risk factors; additionally,
appropriate control of diabetes mellitus, systolic blood
pressure, and current smoking could lead to substantial
reduction in stroke risk.
The main limitations of the present study are the use of
risk score to estimate the 10-year stroke risk. Participants
were recruited on the voluntary basis, so the study sample was not established by random sampling but it
covered all major demographic strata of the Thai general
population.8 However, the study was large sample
size and participants were enrolled from the general

P value
,.001

.012
,.001

1.00

1.52 1.00-2.33
1.99 1.29-3.06
3.75 2.47-5.69
,.001
1.00

1.19 .94-1.50
1.38 1.07-1.78
1.52 1.24-1.87
1.40 1.12-1.75
.004
1.00

1.48 1.04-2.11
1.68 1.14-2.48
1.21 1.07-1.37

.002

*35 Thai baht z 1 US dollar in 2009 and 32 Thai baht z 1 US

dollar in 2013.

are inconsistent.24 In the present study, the association between lower SES and stroke could be partly explained by
a higher burden of conventional risk factors in the lower
SES group because high estimated 10-year stroke risk in
this study was estimated based on conventional risk factors comprising the risk score. In addition, our study
showed that unemployed/house work and illiterate class
were more related to increased stroke risk compared with
low personal income.

Table 3. Impact of a risk score component on high estimated 10-years risk of stroke ($10%) in multiple logistic regression analysis
Nonstandardized coefficients
Variable

Beta

Standard error

Standardized beta coefficients

P value

Age
Sex (male)
Diabetes mellitus
Systolic blood pressure
Current smoking
Antihypertensive treatment
Body mass index
Diastolic blood pressure

.690
5.896
6.710
.088
4.045
3.197
.221
.026

.025
.235
.239
.004
.199
.161
.017
.007

4.733
2.763
2.442
1.920
1.402
1.226
.921
.325

,.001
,.001
,.001
,.001
,.001
,.001
,.001
,.001

Educational level, low personal income, occupation, geographic area, alcohol consumption, and hypercholesterolemia were also included in
the model.

S. HANCHAIPHIBOOLKUL ET AL.

population from 5 regions around the country rather than

selected population.

Conclusions
To sum up, SES, geographic area, alcohol consumption,
and hypercholesterolemia were significant predictors of
high estimated 10-year stroke risk. Unemployed/house
work and illiterate class were strong predictors. Among
factors comprising the risk score, age, male sex, diabetes
mellitus, systolic blood pressure, and current smoking
were of a greater impact on stroke risk. These findings
suggest that SES, in particular, unemployed/house
work, and illiterate class are good proxy to identify the individuals at higher risk of stroke. Clinical preventive
focus targeting these disadvantaged population groups
may reduce the high burden of stroke in the population.
Acknowledgment: The authors thank the neurologists
and staff of the Prasat Neurological Institute for their cooperation in this study. Appreciation is extended to staff of Sankampang Hospital, Khon Kaen Provincial Health Office,
Buddha-Sothorn Hospital, and Nakhon Si Thammarat
Provincial Health Office for their participation in the survey.

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