J Community Health (2013) 38:919925
DOI 10.1007/s10900-013-9702-0
ORIGINAL PAPER
Ischemic Heart Disease and Its Related Factors in Mongolia:
A Nationwide Survey
Tsogzolbaatar Enkh-Oyun Kazuhiko Kotani
Dambadarjaa Davaalkham Yasuko Aoyama
Satoshi Tsuboi Taeko Oguma Yosikazu Nakamura
Published online: 16 May 2013
Springer Science+Business Media New York 2013
Abstract Ischemic heart disease (IHD) remains one of
the most important disorders associated with disability and
mortality worldwide, and is one of the major causes of
cardiovascular diseases in Mongolia. The objective of the
current study was to determine the prevalence of IHD and
its related factors in a general population in Mongolia. We
conducted a nationwide cross-sectional survey between
March and September, 2009. General participants were
recruited from urban to rural regions in a multistage ran-
dom cluster sampling method. The diagnosis of IHD was
based on the Rose questionnaire (World Health Organiza-
tion) and electrocardiographic findings. A total of 369
(16.2 %) subjects with IHD were diagnosed among 2,280
participants. The prevalence of subjects with IHD was
significantly increased by age: from 9.9 % in individuals
age 4044 years compared to 17.7 % in those over
60 years. Smoking habits (former and current) and non-
frequent intake of fruits and vegetables were significantly
positively associated with IHD in men, while heavy alcohol
drinking habits and lower education period of time were
significantly positively associated with IHD in women.
IHD was found to be prevalent, especially among people
aged over 40 years, in Mongolia. Statistical factors related
to IHD were found to be significantly different based on
sex. The current data may provide relevant information to
prevent IHD in the Mongolian population.
T. Enkh-Oyun (&)
K. Kotani
Y. Aoyama
S. Tsuboi

T. Oguma
Y. Nakamura
Department of Public Health, Jichi Medical University,
3311-1 Yakushiji, Shimotsuke City, Tochigi 329-0498, Japan
e-mail: enkhoyun_t@yahoo.com
D. Davaalkham
Department of Epidemiology and Biostatistics, Health Sciences
University of Mongolia, Ulaanbaatar, Mongolia
Keywords Ischemic heart disease
Mongolia

Prevalence
Cross-sectional study
Introduction
Ischemic heart disease (IHD) is characterized by ischemia of
the heart tissues due to atherosclerosis of the coronary
arteries [1, 2]. Several risk factors have been identified,
including age, male gender, smoking, alcohol use, lower
intake of fruit and vegetables, physical inactivity, and car-
diometabolic disorders [1, 2]. In 2004, IHD was the leading
cause of mortality in the world accounting for 12.2 % of all
deaths [1]. The WHO projected that by 2030 the percentage
of deaths due to IHD will increase up to 14.2 % and will
remain the leading cause of mortality [1]. Three-fourths of
global deaths due to IHD occurred in low- and middle-
income countries, with increasing longevity, urbanization,
and lifestyle changes [2]. The mortality of IHD is also the
leading cause of total mortality in Mongolia, and one report
documented that the mortality of IHD in men in age group
4565 years was 3.1 times higher than in women in the same
age group [3]. However, there has been little information on
the epidemiology of IHD in Mongolia. More data for the
prevention of IHD, such as the real prevalence and its related
risk factors of IHD, are needed.
As a recent topic, socioeconomic status (SES) can play a
role in the development of IHD [4, 5]. Previous studies have
shown that a lower SES is associated with IHD [6, 7]. From a
the results of a Chinese study that investigated the associa-
tion of SES with myocardial infarction, low levels of edu-
cation were more commonly found in cases with myocardial
infarction compared to controls [7]. The SES indicators,
such as education levels, were predictive for the incidence of
heart failure among patients with IHD in Israel [6]. A
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relationship between SES and health is of particular interest
in Mongolia, which is globalizing at an accelerated pace and
has rapid changes of the socioeconomic environment.
However, there have been no studies on the relationship
between SES and IHD in Mongolia.
Again, no epidemiologic surveys exist focusing on IHD
and its related factors among the general Mongolian pop-
ulation [3], although several surveys have been conducted
for subjects with background diseases to IHD, such as
hypertension, in Mongolia [811]. Because the surveys that
were recruited from living people exclude sufferers from
sudden death caused by IHD, this often makes difficult the
exact statistics related to IHD. In order to develop strate-
gies for the prevention of IHD, although we acknowledge
omitting the specific cases from sudden death caused by
IHD, it is crucial for us to have nationwide updated data for
subjects with IHD in the Mongolian population. The
objective of the current study was, therefore, to determine
the prevalence of the IHD and its related factors in a
general population of Mongolia.
Methods
We conducted a nationwide cross-sectional study among
the general population in Mongolia. A total of 2,280 people
were enrolled in this study. The study was approved by the
Ethics Committee of the Ministry of Health, Mongolia in
20th of January in 2009 and these subjects gave their
written consent.
Data Collection
A total of 2,280 randomly selected Mongolian people aged
over 40 years from 8 rural soums (counties/villages) and 4
provincial centers of 4 provinces, and 14 khoroos of 4
districts of Ulaanbaatar city participated in the survey. Data
was collected from March 2009 through August 2009. The
survey was designed to cover all geographical areas of
Mongolia, and a four-stage cluster sampling process was
carried out to randomly select participants from the target
population. Given the urban versus rural differences in
lifestyle and disease status, the target population was
stratified into urban and rural areas and samples were
drawn proportionally from each based on the target popu-
lation in each area. Before the study, we distributed an
information sheet which explained the purpose of the study
to subjects, who were randomly selected by the registration
of general practitioners. Subjects were invited to local
general practitioner centers in the urban districts, local
rural soum clinics, and provincial centers.
A standard questionnaire of the WHO STEPS Surveil-
lance Manual was used [12]. The questionnaire consisted
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J Community Health (2013) 38:919925
of eight chapters with a total of 80 closed-ended and open-
ended questions. This questionnaire included their SES,
alcohol and tobacco use, nutrition, physical activity, and
health status. Subjects answers to the questionnaires were
confirmed by interviews. Physical examinations were
conducted following an overnight fast.
Physical Examinations
Height was measured in centimeters (without shoes), and
weight was in kilograms (with heavy clothing removed).
Body mass index was calculated as weight in kilograms
divided by the square of height in meters. Overweight and
obesity were defined according to the WHO definition of a
BMI greater than or equal to 25 as overweight and a BMI
greater than or equal to 30 as obesity. Two blood pressure
recordings were obtained from the right arm of participants
in a sitting position after 10 min of rest, and mean values
were calculated. Percentage of hypertension was defined as
follows: systolic blood pressure C140 and diastolic blood
pressure C90 mmHg or currently on medication for
hypertension. In fasting blood samples, concentrations of
total cholesterol and glucose were measured. According to
the WHO criteria using a fasting concentration [13],
impaired glucose tolerance (IGT) was defined as a glucose
level of equal to 6.16.9 mmol/L, diabetes mellitus was
defined as a glucose level of higher than 7.0 mmol/L, and
hypercholesterolemia was defined as total cholesterol of
higher than 5.0 mmol/L, respectively.
SES Variables
Education variables, such as the start of and total years of
education, were collected, and categorized per the Mon-
golian education system, dividing into 5 categories as
elementary (\7 years), incomplete secondary (79 years),
complete secondary (1012 years), vocational [13, 14], and
university graduates ([14 years). Monthly income was
categorized into the 3 types of lower, middle, and upper
levels according to the average salaries per month (Mon-
golian National Statistic Office 2009).
Socioeconomic position was measured and defined as
social classes based on the longest held occupation, using a
Registrar Generals Classification [14], where Class I cor-
responded to the upper social class. Participants were
placed into 6 groups of social class I (professional, e.g.,
physicians, engineers), social class II (managerial e.g.,
teachers, sales managers, social class III (semi-skilled non
manual, e.g., bricklayer), social class IV (partly skilled e.g.,
postmen), social class V (unskilled e.g., porters, laborers),
and non-employed VI (retired, unemployed, housewives).
Persons classified as housewives, students, retired with no
information on last occupation or persons whose stated
J Community Health (2013) 38:919925 921

occupation could not be classified, and were placed in a
social class VI which means non employed group.
IHD Diagnosis
The Rose questionnaire and electrocardiography (ECG)
were applied to the diagnosis of IHD [15]. In comparison
with clinical judgment, the Rose questionnaire has been
found to have 7881 % sensitivity and 9497 % specificity
[1, 16, 17]. Twelve-lead ECGs were taken by trained
individuals using Cardiomax electrocardiographs. The
electrocardiograms from the study participants were ana-
lyzed by the cardiologists with their corresponding Min-
nesota codes [18].
odds ratios for evaluating the association between inde-
pendent variables and IHD. Adjustments were carried out
for the independent variables which significantly associ-
ated with IHD by Chi square test; that is, age, education,
smoking habits, alcohol consumption and fruit/vegetable
consumption habits. The trend in odds was evaluated by
using the likelihood ratio test for trend. All probability
values were two-tailed, and all confidence intervals were
estimated at the 95 % level. The Statistical Package for the
Social Sciences (SPSS Version 18.0) was used for analysis.
A statistical significance was set at P \ 0.05.
Results

Statistical Analysis Table 1 shows that descriptive statistics of IHD. The

prevalence of IHD was 16.2 % in the study population
The association between the measured variables and aged 40 years and over. The prevalence of IHD did not
prevalence of IHD was analyzed by the Chi square test. differ by sex. There was an increase of IHD correlated with
Logistic regression analyses were used to calculate the age in both sexes (in particular, statistical significance of

Table 1 Descriptive statistics of study population

Entire IHD, P value Total Men with P value Total Women with P value
population, n n (%) men, n IHD, n (%) women, n IHD, n (%)

Total 2,280 369 (16.2) 851 134 (15.7) 1,429 235 (16.4)
Age group (years) 0.003 0.062 0.003
4044 424 42 (9.9) 144 16 (11.1) 280 26 (9.3)
4549 525 87 (16.6) 189 34 (18.0) 336 53 (15.8)
5054 499 88 (17.6) 181 22 (12.2) 318 66 (20.8)
5559 362 69 (19.1) 141 31 (22.0) 221 38 (17.2)
60? 470 83 (17.7) 196 31 (15.8) 274 52 (19.0)
Residence 0.109 0.087 0.519
Urban 1,267 191 (15.1) 479 66 (13.8) 788 125 (15.9)
Rural 1,013 178 (17.6) 372 68 (18.3) 641 110 (17.2)
Monthly income 0.211 0.495 0.401
Lower 967 162 (16.8) 333 56 (16.8) 634 106 (16.7)
Middle 584 103 (17.6) 226 38 (16.8) 358 65 (18.2)
Upper 729 104 (14.3) 292 40 (13.7) 437 64 (14.6)
Education (year) 0.030 0.196 0.078
Elementary 230 47 (20.4) 68 10 (14.7) 162 37 (22.8)
Incomplete secondary 531 97 (18.3) 253 48 (19.0) 278 49 (17.6)
Complete secondary 606 102 (16.8) 221 39 (17.6) 385 63 (16.4)
Vocational 357 53 (14.8) 82 9 (11.0) 275 44 (16.0)
University 556 70 (12.6) 227 28 (12.3) 329 42 (12.8)
Occupation 0.195 0.154 0.654
Social class I 690 93 (13.5) 261 29 (11.1) 429 64 (14.9)
Social class II 431 67 (15.5) 117 20 (17.1) 314 47 (15.0)
Social class III 115 23 (20.0) 31 6 (19.4) 84 17 (20.2)
Social class IV 90 15 (16.7) 72 12 (16.7) 18 3 (16.7)
Social class V 199 34 (17.1) 88 12 (13.6) 111 22 (19.8)
Social class VI 755 137 (18.1) 282 55 (19.5) 473 82 (17.3)

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the trend was observed in women as well as men). The
education year indicator was significantly associated with
the prevalence of IHD in the whole study population, and
this was noted to be particularly significant in women.
Women with only an elementary education had a higher
prevalence of IHD (22.8 %) compared with women who
had university degrees (12.8 %).
Smoking was significantly associated with IHD in men
(Table 2). IHD was more prevalent in current and ex-smokers
(19.3 and 18.2 %) than in non-smokers (10.0 %). In contrast,
alcohol consumption was significantly associated with IHD in
women. IHD prevalence was higher in heavy drinkers (20.6)
but of lower prevalence in low moderate drinkers (11.0 %).
Insufficient intake of fruit and vegetables were significantly
associated with IHD in men. Men who did not consume
vegetables or fruit had higher prevalence of IHD (25.6 and
20.1 %) compared to those who did consume them. Obesity,
hypertension, hypercholesterolemia, and glucose disorders
were not significantly associated with the prevelence of IHD.
Table 3 shows the odds ratios for IHD as dependent
variable. Single variate analyses showed that smoking
habits (former and current smokers) (odds ratio
[OR] = 1.84; 95 % confidence interval [CI] 0.983.44 and
OR = 2.15; 95 % CI 1.373.40) and non-frequent intake
of fruits (OR = 1.66; 95 % CI 1.142.40) and vegetables
(OR = 1.99; 95 % CI 0.571.64), were significantly posi-
tively associated with IHD in men. These results were
attenuated in a multivariate regression analysis, and only

Table 2 The prevalence of IHD by related factors

Entire IHD, P value Total Men with P value Total Women with P value
population, n n (%) men, n IHD, n (%) women, n IHD, n (%)

Walking habits ([10 min/day) 0.428 0.377 0.759

Yes 1,935 308 (15.9) 709 108 (15.2) 1,226 200 (16.3)
No 345 61 (17.7) 142 26 (18.3) 203 35 (17.2)
Vegetable consumption habits 0.149 0.021 1.000
Yes 2,090 331 (15.8) 773 114 (14.7) 1,317 217 (16.5)
No 190 38 (20.0) 78 20 (25.6) 112 18 (16.1)
Fruit consumption habits 0.119 0.009 1.000
Yes 1,605 247 (15.4) 532 70 (13.2) 1,073 177 (16.5)
No 675 122 (18.1) 319 64 (20.1) 356 58 (16.3)
Alcohol consumption habits 0.008 0.093 0.017
Non 911 154 (16.9) 211 32 (15.2) 700 122 (17.4)
Low moderate 429 49 (11.4) 101 13 (12.9) 328 36 (11.0)
High moderate 380 58 (15.3) 144 15 (10.4) 236 43 (18.2)
Heavy 560 108 (19.3) 395 74 (18.7) 165 34 (20.6)
Smoking habits 0.081 0.002 0.893
Non smoker 1,600 241 (15.1) 311 31 (10.0) 1,289 210 (16.3)
Current smoker 548 104 (19.0) 430 83 (19.3) 118 21 (17.8)
Ex smoker 132 24 (18.2) 110 20 (18.2) 22 4 (18.2)
Hypercholesterolemia 0.543 0.466 0.845
Yes 382 66 (17.3) 157 28 (17.8) 225 38 (16.9)
No 1,895 303 (16.0) 694 106 (15.3) 1,201 197 (16.4)
Obesity traits 0.975 0.866 0.793
Normal 814 133 (16.3) 315 47 (14.9) 499 86 (17.2)
Overweight 852 136 (16.0) 322 53 (16.5) 530 83 (15.7)
Obesity 614 100 (16.3) 214 34 (15.9) 400 66 (16.5)
Glucose disorder 0.300 0.264 0.401
Normal value 1,929 322 (16.7) 715 119 (16.6) 1,263 203 (16.7)
Impaired glucose tolerance 168 22 (13.1) 65 6 (9.2) 106 16 (15.5)
Diabetes 183 25 (13.7) 71 9 (12.7) 57 16 (14.3)
Hypertension 0.288 0.920 0.260
No 826 130 (15.7) 349 54 (15.5) 477 76 (15.9)
Previously diagnosed 861 152 (17.7) 292 48 (16.4) 569 104 (18.3)
Diagnosed by study 593 87 (14.7) 210 32 (15.2) 383 55 (14.4)

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Table 3 Odds ratio for the IHD as dependent variable and related factors as independent variables
Entire population Men Women
Unadjusted OR Multivariate OR Unadjusted OR Multivariate OR Unadjusted OR Multivariate OR
(95 % CI) (95 % CI) (95 % CI) (95 % CI) (95 % CI) (95 % CI)

Age group (years)

4044 1.0 1.0 1.0 1.0 1.0 1.0
4549 1.81 (1.222.68)* 1.78 (1.202.66)* 1.76 (0.933.32) 1.82 (0.953.51) 1.83 (1.113.01)* 1.84 (1.113.05)*
5054 1.95 (1.312.89)* 1.96 (1.622.92)* 1.11 (0.562.19) 1.11 (0.552.24) 2.56 (1.574.16)* 2.61 (1.604.28)*
5559 2.14 (1.423.24)* 2.18 (1.423.30)* 2.26 (1.174.34)* 2.39 (1.224.72)* 2.03 (1.193.46)* 2.10 (1.223.62)*
60? 1.95 (1.312.90)* 1.87 (1.232.83)* 1.50 (0.792.87) 1.75 (0.893.44) 2.29 (1.383.79)* 2.10 (1.223.62)*
Education (years)
Elementary 1.0 1.0 1.0 1.0 1.0 1.0
Incomplete 0.87 (0.591.28) 0.89 (0.591.35) 1.36 (0.652.85) 1.58 (0.723.47) 0.72 (0.451.17) 0.75 (0.451.27)
secondary
Complete 0.79 (0.541.16) 0.88 (0.581.37) 1.24 (0.582.64) 1.61 (0.713.67) 0.66 (0.421.04) 0.70 (0.411.19)
secondary
Vocational 0.68 (0.441.05) 0.75 (0.441.27) 0.72 (0.271.88) 1.04 (0.353.07) 0.64 (0.391.05) 0.59 (0.311.10)
University 0.56 (0.370.84)* 0.64 (0.381.09) 0.82 (0.371.78) 1.30 (0.493.50) 0.49 (0.300.81)* 0.50 (0.260.97)*
Smoking habits
Non smoker 1.0 1.0 1.0 1.0 1.0 1.0
Current 1.32 (1.031.70)* 1.19 (0.911.56) 2.01 (1.093.69)* 2.15 (1.373.40)* 1.11 (0.681.82) 0.97 (0.591.61)
smoker
Ex smoker 1.25 (0.791.99) 1.10 (0.681.78) 2.16 (1.393.36)* 1.84 (0.983.44)* 1.14 (0.383.40) 0.99 (0.323.08)
Alcohol consumption habits
Non 1.0 1.0 1.0 1.0 1.0 1.0
Low moderate 0.63 (0.450.89)* 0.69 (0.480.98)* 0.83 (0.411.65) 0.81 (0.401.66) 0.58 (0.390.67)* 0.66 (0.440.99)*
High moderate 0.89 (0.641.23) 0.98 (0.701.39) 0.65 (0.341.25) 0.67 (0.341.32) 1.06 (0.721.55) 1.26 (0.841.89)
Heavy 1.18 (0.891.54) 1.20 (0.891.60) 1.29 (0.822.03) 1.27 (0.792.05) 1.23 (0.801.88) 1.38 (0.892.16)
Vegetable consumption habits
Yes 1.0 1.0 1.0 1.0 1.0 1.0
No 1.33 (0.911.93) 1.15 (0.771.74) 1.99 (1.163.44)* 1.79 (0.963.33) 0.97 (0.571.64) 0.84 (0.481.49)
Fruit consumption habits
Yes 1.0 1.0 1.0 1.0 1.0 1.0
No 1.21 (0.961.54) 1.01 (0.781.31) 1.66 (1.142.4)* 1.36 (0.902.05) 0.99 (0.711.36) 0.87 (0.611.24)
Odds ratio [OR] (95 % confidential interval [CI]) adjusted for age, education, smoking, alcohol consumption habits and vegetable, fruit
consumption habits
* P value \0.05

current smoking habits (adjusted OR = 2.13; 95 % CI
1.373.40) remained significant risk factors for IHD in
men. In multiple logistic regression models, increasing age
(OR = 2.10; 95 % CI 1.223.62), heavy rather than low
moderate alcohol drinking habits (OR = 0.66; 95 % CI
0.440.099) and lower levels of higher education
(OR = 0.50; 95 % CI 0.260.97) were significantly asso-
ciated with IHD in women.
Discussion
The current study was the first survey conducted nation-
wide on the prevalence of IHD in the general population of
Mongolia, as well as attempting to determine associated
risk factors, including SES indicators. The prevalence of
IHD was 16.2 % in this population. There were population-
based studies in Tehran, Iran (age C30, n = 5,984) [19]
and in India (age C20, n = 1,047) [20] using the same
methodology as ours, namely the Rose questionnaire and
ECG studies. The prevalence of our surveys is lower than
the 21.8 % reported in the Tehran study and higher than the
7.1 % reported in the Indian study [19, 20]. Given these
previous data, IHD appears to have a relatively high
prevalence in Mongolia. As for age, increasing trends were
observed with age and prevalence of IHD, and subjects
over age 60 had the highest prevalence of IHD, regardless
of sex. This result is consistent with the previous studies in

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Tehran and India [19, 20]. As for the sex difference in the
prevalence of IHD, the previous studies reported that
women had a higher prevalence of IHD than men: women:
22.3 % and men: 18.8 % in the Tehran study [19] and
women: 8.9 %, men: 6.2 % in Indian study [20]. Although
the prevalence of IHD was slightly higher in men (16.4 %)
compared with women (15.7 %) in our survey, the preva-
lence was nearly equal between the sexes. This trend in
Mongolia seems rather inconsistent to general trends of the
prevalence of IHD, suggesting the need for further
investigation.
The current study found a significant association
between smoking and IHD in men. Smoking is well known
to be a causatively associated with IHD, and cigarette
smokers are 24 times more likely to develop IHD than
nonsmokers [21]. The highest incidence of smoking is
generally observed among men in lower-middle-income
countries, and among Mongolian adults, 24.3 % were
found to be smokers (43 % men, 5.2 % women) in 2009
[22]. The fraction of IHD attributable to smoking was
estimated to be 25 % in Mongolian men [23], and the anti-
smoking policy is thought to be effective for preventing
IHD events in this population. In addition, non-frequent
fruit and vegetable consumption were significantly asso-
ciated with IHD in men. This supports the previous reports,
while these reports also show that the findings were
observed in both sexes [29, 30]. Mongolian men were more
unlikely to eat fruit and/or vegetables than women [22, 31],
and this trend, in particular regarding fruit consumption,
was notable in the current study. Such sex differences of
dietary habits in Mongolian people may explain the sex-
based differences observed in the current study.
Among women, low moderate drinking of alcohol was
associated with a lower prevalence of IHD. This was con-
sistent with the previous studies [24, 25]. Light to moderate
drinking can have a beneficial impact on morbidity and
mortality of IHD [26]. The association between alcohol and
IHD among women, rather than men, may be due to factors
such as menopausal states and stronger effects of alcohol on
women [27, 28]. In addition, among women, those with
lower levels of education were noted to have significantly
higher prevalence of IHD. The association of education years
on the prevalence of IHD is the first to be shown in Mongolia.
This result is likely similar to the studies conducted in Israel,
China and the USA [6, 32]. The mechanisms of involvement
of educational attainment in the development of IHD remain
unclear, but as an example, persons of lower SES are thought
to confront more barriers to modifying risk behaviors over
time such as quitting smoking, improving diet, increasing
physical activity and adhering to medications [33]. In our
study, odds ratios for IHD in women decreased linearly as
level of education increased. The association between edu-
cation and IHD in our current study was clearly observed in
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J Community Health (2013) 38:919925
women, but not in men. In Mongolian tradition, in terms of
education, many parents are more concerned about daugh-
ters than sons in the teenage years, and girls therefore have a
wider range of opportunities to obtain higher education. This
may partly affect the sex difference observed in the current
study.
There are several limitations in our study. The cross-
sectional design might allow for less ability to determine
the causal relationship between IHD and its related factors.
The prevalence of IHD might not exactly reflect all cases of
IHD because cases of sudden death caused by IHD would
have eliminated those individuals from inclusion in the
study. Future studies with a prospective design and
enrollment of all cases with IHD are therefore warranted.
Conclusion
In conclusion, IHD was found to have a high prevalence,
especially among people over 40 years of age, in Mongo-
lia. Significant factors related to IHD were found to have
some differences according to gender. The current data
may provide relevant information to help prevent IHD in
the Mongolian population.
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