71 Risk factor clustering by sex in the Southern Cone of Latin America 3 Our findings show that the most common combination of RF in participants with ≥ 4 RF is hypertension / dyslipidemia / obesity / unhealthy diet; followed by combinations that include hypertension and obesity combined with diabetes, dyslipidemia, unhealthy diet and low physical activity. Previous research found the most prevalent combinations in CHD patients in Iran were dyslipidemia / low physical activity and dyslipidemia / central obesity (7), while in healthy individuals in China the most common cluster in was hypertension / dyslipidemia / obesity (8). This overlaps partly with our results, as dyslipidemia and obesity were components of the most common clusters. There were some differences, as hypertension was a component of many of the highly prevalent combinations in our study, but it was not part of the most frequent combinations in Iranian CHD patients. However, they calculated the prevalence of combinations of two RF, while we analyzed combinations of 3 and 4 RF. We also observed sex differences in some of the most prevalent combinations. Wang et al (10) compared RF clustering in Chinese and Dutch men and women, finding that the most frequent clusters included drinking in men and obesity in women among Chinese, and obesity and hypertension in Dutch women. In our study we found significant sex differences in some combinations including physical inactivity (more common in women), and alcohol use and smoking (more common in men). In both studies, excessive alcohol use was part of the most the frequent clusters in men. There were also some differences: smoking was part of the combinations that were more common in men in our study, but it was present in the highly prevalent clusters in both men and women in the Dutch and the Chinese populations. This is an example of how the composition of RF clusters, as well as the different cluster composition by sex, can have regional variations (10). It is important to investigate the specific components of RF combinations, as it has been shown that different combinations have differential risks for cardiovascular mortality and morbidity (6,35,37). Studies carried out in The Netherlands in individuals with high CVD risk and in a healthy population in Asia showed that combinations including hypertension (35,37) and smoking (35) are associated with higher risks for CVD events. This is of concern since in our study since hypertension was a component in most highly prevalent combinations in individuals with at least 4 RF. However, there are regional differences in the risks associated with individual combinations, and therefore it would be important to research the risk of cardiac events associated with individual RF combinations specifically for the Southern Cone of Latin America. Unfortunately, this is not possible in our study due to the cross-sectional nature of the data. Cardiometabolic RF were more common than lifestyle RF in men and women in the CESCAS Study population. There were sex differences in the number of cardiometabolic RF, with women presenting a higher number, but not on the lifestyle RF. Previous literature also finds a predominance of cardiometabolic RF, although in this case they were more common in men (38). The modification or control of cardiometabolic RF is dependent on lifestyle changes and medication use. In our results, although lifestyle factors had a lower burden than cardiometabolic RF, there was a high prevalence of unhealthy diet and low physical activity. Although there may be other factors at play, the fact that there are sex differences in
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