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Varicose Veins: Addressing Vascular Health Disparities

Varicose veins are superficial, enlarged, and twisted blood vessels and are often thought of as a sign of age. However, these abnormally dilated vessels are often seen in younger people and are more common in women than in men. They occur in up to half of the adult population and are a frequently underdiagnosed and undertreated condition. Varicose veins are associated with superficial thrombophlebitis and clot in the dilated veins, chronic leg swelling and skin changes, and in their most severe form, with ulceration. Treating the ulcers and their complications can have a profound effect on reducing mobility and increasing dependency. Venous insufficiency and varicose veins are a significant cause of morbidity in the population, which proportionally increases with age. However, they are also an undertreated condition when compared to their contribution to quality of life, as they are not a life-threatening condition. Therefore, there is a need to address and treat varicose veins and prevent the progression of venous disease in the elderly.

Understanding Varicose Veins

Varicose vein is often inherited, and if there is a family history of them, it is likely that they will develop sooner than people whose families do not suffer. Between 600,000 and 800,000 people in the UK have more severe varicose veins, and skin changes can occur, leaving brown discoloration or eczema.

Pregnancy can cause varicose veins. The higher levels of estrogen and progesterone cause the walls of the veins to relax. Women also tend to find that their varicose veins get worse during the menstrual cycle or during menopause.

Causes of Varicose Veins The main cause is that the wall of the vein weakens and its elasticity is lost. This results in blood pooling in the veins and the pressure causes them to become distorted and bulge. Varicose veins are more common in women than men, and the risk increases with age.

Veins carry blood from all parts of the body to the heart. The blood flow from the legs to the heart is against gravity. There are tiny valves in the veins which open as blood flows toward the heart and close to stop blood flowing backwards. Varicose veins develop when the small valves inside the veins stop working properly and allow blood to flow backwards. The cause of varicose veins is not fully understood, but there are a number of theories.

Causes of Varicose Veins

Valves there prohibit reverse and downward flow of blood, but if these fail, it can cause increased pressure on the veins. Arterial flow to the veins is increased, and this added pressure leads to the veins becoming dilated and distorted. Damaged veins are fragile and subject to easy, repeated trauma. Gradual valve damage can result from a one-time or several-time occurrence of Deep Vein thrombosis (blood clot). Deep vein thrombosis can also cause varicose veins due to veins being blocked by the clot and hindering normal blood flow to the heart. Pelvic tumors in close proximity to the pelvic veins can cause a condition known as pelvic congestion syndrome. This is similar to varicose veins in that the dilation of the veins occurs, but usually on the veins on the outer thigh and lower abdomen. High levels of estrogen can weaken vein walls, and this explains why women get varicose veins more often than men. Pregnancy also has a similar effect due to the increase in blood volume that does not match the weakened vein walls. Please note that obesity is omitted, as explained previously. Its relevance to the cause of varicose veins is potential damage to the veins due to the excess weight, which resembles the general cause of varicose veins due to increased pressure on the veins.

Symptoms and Complications

The symptoms of varicose veins are usually mild and can include aching legs, swollen ankles or feet, leg cramps, and a feeling of heaviness or fatigue in the legs. Severe varicose veins can lead to more serious problems. A long-term buildup of blood in a varicose vein can cause the vein to become hard (a condition known as sclerosis) because the skin is not very elastic. This can then lead to a change in color of the skin on the vein. Eczema may then develop on the skin.

Varicose veins are large, swollen veins that often appear on the legs and feet, but they can appear on any part of the body. They are caused by improperly functioning vein valves, usually in the legs. Our blood vessels are part of the circulatory system that returns blood to the heart. When we stand or walk, gravity pushes down on the veins in the lower part of our body, especially the legs. This puts more pressure on our lower body veins compared to our upper body veins. Normally, the veins use one-way valves to prevent the backflow of blood when under pressure. However, when these valves start to leak, blood flows backwards and pools in the vein, causing it to swell. This is the cause of varicose veins.

Vascular Health Disparities

Public health disparities are differences in the incidence, prevalence, and morbidity of a condition among a certain group compared to the general population. There are many public health disparities that occur among different races and cultures. In the case of varicose veins, the disparities are not well documented, however it is a common belief within the vascular surgery community that certain populations suffer from the condition at a higher rate, and that they are more likely to suffer from the more severe symptoms of the disease. Data from the Framingham Study has shown that African-Americans have an approximately 3-fold increased risk of developing venous insufficiency, which is a more severe form of chronic venous disease as compared to their white counterparts. This can be attributed to the fact that varicose veins are a result of venous insufficiency which is a condition primarily caused by dysfunctional or refluxing valves in the superficial and deep veins. The SEVE (Societé Esperanto Vena) Clinical Guidelines Committee has stated that there is a higher prevalence of more severe forms of chronic venous disease in some population groups and must be viewed as a public health problem in those communities. The SEVE is an international organization consisting of vascular specialists, thus it is a consensus from the medical community that this is a public health issue for specific populations. Unfortunately, there is no data that analyzes why certain populations suffer from the condition more than others. This is an important area for future research as to stop disparities, the cause must be identified.

Factors Contributing to Disparities

Many factors contribute to the disparities in vascular health. Some are societal, some are related to healthcare, and some are related to the nature of the disease. Socioeconomic status is a factor in the cause and treatment of varicose veins. Those of middle to high economic status usually exhibit milder symptoms or seek treatment earlier. They are often able to seek prevention and elective treatment of their venous disorders. Those of low economic status often end up in the emergency room with a complicated problem which could have been prevented or treated earlier. They may have to work jobs that exacerbate their venous disease and are unable to take time off for conservative treatment measures. Lack of paid sick leave for treatment is related to this factor and can prevent effective treatment of venous disorders. Education is also related to socioeconomic status and is a factor in the cause and treatment of venous disorders. Those with lower education may lack awareness of the causes, preventative measures, and treatment options for their venous disease. This can lead to higher severity of disease at presentation and lack of seeking treatment for their venous disorder. Awareness of preventive measures and early treatment is imperative in reducing the prevalence and burden of venous disease. Simulation studies have suggested that if chronic venous disease could be 10% mitigated, lifetime earnings of the population would be increased by an estimated $300 million. This study also suggested that if all classes of workers had the same low disability rates as the highest income workers, work productivity would increase by an estimated $600-$670 million. This suggests that increasing education and awareness could have a positive impact on the disparity of varicose vein treatment and prevention.

Impact on Different Populations

Varicose vein is the enlarged, swollen, tortuous, and a bulge often found on the skin of the legs caused by various disturbances of venous circulation of blood vessels. Varicose vein occurrence is 10-20% in men and 30-50% in women, mostly in old people. Pregnant women are also prone to varicose veins which are caused due to increasing blood volume that causes circulatory system changes. The occurrence of varicose veins is more common in tropical countries compared to subtropical and cold countries, and among socioeconomic reasons at lower and middle-class people than higher-class people. The level of enzymes α-glucosidase and N-acetyl-α-glucosaminidase in varicose vein were higher than in both great saphenous vein of the elderly and control. The level of those enzymes increased with the severity of varicose vein. This research study was aimed to identify the effects of varicose vein at different ages on the level of enzymes α-glucosidase and N-acetyl-α-glucosaminidase. This research was conducted for an experimental non-randomized clinical approach post-test only control group design. Samples of this research were consumptive patients with varicose vein based on physical examinations (CEAP classification). The level of enzyme α-glucosidase and N-acetyl-α-glucosaminidase of the experimental group aged <50 years and the age of ≥50 years was higher than in the control. This condition was influenced by the aging process at which there were physical limitations and degenerative processes with increasing age, causing decreased vessel vascular smooth muscle cell and the endothelial cells. The changes in muscle cell and the increased endothelial cells lead to inflammation process and the occurrence of venous wall neovascularization, which will increase vascular permeability and finally cause chronic venous insufficiency.

Addressing Disparities through Education and Awareness

Community-based education and awareness initiatives have been used to address disparities related to vascular diseases. The North Carolina Baptist Hospitals’ VeinCare program successfully used community-based education programs to increase awareness about chronic venous insufficiency (CVI) and its more serious form, venous ulcers. The objectives of this program were to increase public awareness and understanding of venous disease and its potential effects, to improve accessibility of evidence-based, best practice treatment for venous disease, and to advocate for policy changes that would improve the prevention and management of venous disease. Low health literacy often leads to significant disparities in awareness, prevention, and treatment of diseases. It is a major cause of health disparities and a silent barrier that can restrict an individual from achieving their full health potential. Kaiser Permanente conducted a randomized trial to determine the effectiveness of a literacy-appropriate educational intervention to improve knowledge and self-management skills for patients with chronic disease. The intervention made substantial improvements in patients’ understanding. They showed a 4-5 fold increase in knowledge and self-management skills. By carrying out this intervention, Kaiser Permanente demonstrated the potential for increasing disease-specific knowledge and self-management skills among those affected by various diseases.

Strategies for Prevention and Treatment

Lifestyle changes are perhaps the most cost-effective method of preventing the progression and appearance of varicose veins. This can be achieved through regular physical activity that works the calf muscle pump and/or weight loss programs that reduce the BMI to a normal range. Patients with occupations that require long periods of standing or sitting can attempt to alter their work environment to include periodic rest breaks with leg elevation. Data shows that periodic calf muscle exercise effectively reduces the ambulatory venous hypertension that leads to the progression and appearance of varicose veins. This can be accomplished through daily exercise regimens or through prompt recognition and treatment of associated pathologies such as post-thrombotic ulcerations. Weight loss programs that reduce the BMI to a normal range can delay and/or prevent the development of varicose veins at various saphenous and perforator junctions through the reduction of ambulatory venous hypertension. This can be accomplished through BMI reduction with dietary changes or through invasive surgeries such as saphenous stripping or bypass. These occupations typically lead to the development of symptoms, and in severe cases, skin changes and ulcerations.

The implementation of specific prevention strategies and treatments can reduce the disability, social, and economic impact of varicose veins and chronic venous diseases. Prevention strategies include lifestyle changes, the use of compression stockings, and minimally invasive medical and surgical treatments for symptomatic varicose veins. Changes in lifestyle can reduce the risk of developing varicose veins and can delay the progression to more severe forms of chronic venous diseases. Treatment options can improve the symptoms and the appearance of varicose veins. There are few data on the implementation of varicose vein prevention and treatment strategies on a public health and community-wide basis. Epidemiological and outcomes data suggest that the use of these strategies can reduce the overall human and economic burden of varicose veins and chronic venous diseases.

Lifestyle Changes for Varicose Vein Prevention

Leg elevation is an easy and effective means of preventing varicose veins and is best accomplished while resting. When the legs are elevated higher than the heart, blood flows out of the legs and pooled blood is allowed to drain from the veins. Gravity also aids the return of blood to the heart. Leg elevation should be practiced for about 15 minutes at a time, 4 times a day. This routine is especially effective for those with tired, achy legs.

Diet can play a significant role in the development of varicose veins due to the fact that it affects weight and overall cardiovascular health. A low-salt/high-fiber diet is best. Avoiding high sodium, processed foods is advisable. High fiber foods will help prevent constipation, a condition which can contribute to varicose veins. Fruits and vegetables are high in fiber, so increase your intake of these items. Protein is also important, as it supports overall muscle and connective tissue health. Try to include a variety of protein sources in your diet, but avoid high purine proteins (fat meats and dairy), as purines can also adversely affect veins. Avoid spicy or hot foods, as they can dilate veins and increase reflux. Lastly, it is important to maintain adequate water intake. This is essential when increasing fiber consumption as the two work together to prevent constipation. Veins require adequate blood volume to function properly, and water is necessary to maintain blood volume.

Exercise is an essential part of prevention, as it is in the maintenance of good health in general. The most beneficial exercise for those with or prone to varicose veins is walking, as it helps blood move up the legs toward the heart. Stretching and strengthening exercises are also good. Exercise can also help to control weight, another risk factor for varicose veins and chronic venous insufficiency. Caution should be taken to avoid prolonged sitting or standing with legs dependent. This will only serve to pool blood in the lower extremities. If your job requires prolonged sitting or standing, it is even more important that you take time to exercise. When the situation requires long periods of sitting, as in travel, frequent rest stops during which you can prop your feet up can be very beneficial. Legs should be elevated for at least 15 minutes at a time, 4 times a day and after long working and/or prolonged standing hours.

Medical Interventions for Varicose Vein Treatment

Sclerotherapy is a minimally invasive procedure that’s done with local anesthesia and most patients can return to regular activity the following day. The procedure is used to treat varicose and spider veins. A tiny needle can be inserted into a vein and a solution is injected into the vein, causing it to collapse and eventually fade away. There are two forms of sclerotherapy, the older version being liquid sclerotherapy, and the newer version being foam sclerotherapy. Foam sclerotherapy is essentially the same as liquid except the solution is made into foam using arterial gas prior to injection. It is becoming a more popular choice for physicians as an adjunct to other interventions for larger varicose veins. Sclerotherapy varies in success rate, but it is a good option for smaller varicose veins and for venous ulcers and inflammation due to vein malformities. Although sclerotherapy is very technical and there is a risk of further skin damage in inexperienced hands, it is a good adjunct treatment for any patient with symptomatic varicosities.

The first line of treatment for patients with both varicose veins and CVI is compression therapy. Compression therapy is a very useful tool for the management of varicose veins and is used as a minor treatment for the symptoms of CVI. Compression has been shown to reduce swelling of the lower extremity and aid in the skin changes associated with CVI. It can also help reduce the symptoms of edema in the leg that occurs with varicose veins. Although compression therapy may not be the treatment of choice for a young, active individual, it is safe and useful for older individuals who may have other medical problems and for those who are preparing for or recovering from a surgical intervention. Compression therapy for young and/or active individuals may not be the most ideal form of treatment, but it is an important adjunct to the treatment of venous ulcers.

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