{"paper_id":"2b9ca563-e961-47f7-91a9-9afb6b2642e6","body_text":"Assessing Cardiovascular Risk Factors Among College Students In Syrian Private University- A Cross- Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing Cardiovascular Risk Factors Among College Students In Syrian Private University- A Cross- Sectional Study Mhd Homam Safiah, Yasser Kajjoun, Marwan shameih This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8041576/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Assessing cardiovascular risk factors among university students is important as it allows for early intervention and prevention of future diseases. This study aimed to assess the prevalence of cardiovascular risk factors among students at the Syrian Private University. Methods This cross-sectional study was conducted in 2025 using a convenience sampling among students of the Syrian Private University. A self-administered questionnaire in Arabic was distributed to the students. Data were coded and entered into a computer, then analyzed using the Statistical Package for the Social Sciences. Results The study sample consisted of 252 students, with 53.6% male and 46.4% female. Medical students constituted the largest proportion (31.3%), followed by dental students (29%). Current smoking prevalence was 19%. Low physical activity was reported by 43.3%, and 63.9% reported consuming fast food. Sleep disturbances were present in 17.5% of participants. Depressive symptoms were identified in nearly one-third of students (33.7%), while anxiety was reported by 29.8%. Stress was highly prevalent, affecting 81.3% of the students. Overall, 74% of participants had at least two cardiovascular risk factors. Conclusion This study highlights the clustering of cardiovascular risk factors among young adults, particularly obesity and psychological disorders. Early and multidimensional interventions may have a significant impact on reducing the future burden of cardiovascular diseases. CVD Premature CAD Cardiac Risk factors Figures Figure 1 Figure 2 1. Background Recent figures shows that around six million of younger adults globally had Cardiovascular disease (CVD) reflecting public health emergency world-wide ( 1 ). Premature Coronary Artery Disease (CAD), a major class od CVD, is now describe as the fastest epidemic with serious substantial portion of ten-years mortality on the long-term ( 2 ). Although the concerning rates, CVD can be prevented by limiting the wide range of leading risk factors. American heart association noticed the failure of modifying cardiac risk factors among people with premature CAD ( 3 ). The significance of examining cardiac risk factors among university students stems from the opportunity it provides for early intervention and disease prevention, as this stage of life is critical for establishing lifelong health behaviors. Such research also supports the development of targeted, evidence-based health education programs that enhance awareness among young adults, ultimately benefiting society at large. In addition, it offers valuable insights into the influence of behavioral, physiological, and social determinants on cardiovascular health, particularly in the context of contemporary challenges—such as psychological stress—that may contribute to an increased burden of risk factors. 2. Methods 2.1. Study design and Sampling: A cross-sectional survey was conducted between February and April 2025 using a convenience sampling approach among students at the Syrian Private University. Participation was voluntary, and written informed consent was obtained from all respondents. Students were assured that their answers would remain anonymous, that completion of all questions was not obligatory, and that they could withdraw from the survey at any time. Eligibility criteria included being a student at the Syrian Private University, aged 18 years or older. The study objectives were explained in writing and attached to the questionnaire. The required sample size was calculated to be 246 students, based on a total university population of 3,000, using a standard sample size calculator. Ethical approval for the study was obtained from the Institutional Review Board (IRB) of the Faculty of Medicine, Syrian Private University. 2.2. Variables addressed in this research: A structured, self-administered questionnaire in Arabic was distributed to students at the Syrian Private University. The reliability of the instrument was confirmed with a Cronbach’s alpha of 0.754. The questionnaire was designed to capture multiple dimensions of cardiovascular risk factors among university students. It collected information on sociodemographic characteristics, including gender, age, college, year of study, marital status, and place of residence. Medical and family history was assessed through questions on the presence of cardiovascular or metabolic conditions such as hypertension, diabetes, renal failure, and gout, in addition to the use of cardiac medications, family history of cardiac disease among first- and second-degree relatives, and details of prior medical examinations including blood glucose and lipid profile testing, echocardiogram, electrocardiogram, blood pressure measurements, and visits to either the emergency department or a cardiologist. Lifestyle and health behaviors were also evaluated, with items covering smoking, alcohol consumption, physical activity (type, intensity, duration, weekly frequency, and gym membership), and the frequency of fast-food intake. Symptoms and psychological factors were explored through questions on cardiac and general complaints such as palpitations, headache, shortness of breath, dizziness, and fatigue, as well as sleep disturbances, including insomnia and difficulty maintaining sleep. Standardized items were used to assess the severity and frequency of psychological disorders such as anxiety, stress, and depression. Anthropometric indicators were recorded in the form of weight and height, which were used to calculate body mass index (BMI) and assess abdominal obesity. In addition, a female-specific section was included to gather information on menstrual cycle characteristics, including regularity, the presence of polycystic ovary syndrome (PCOS), and the use of medications to regulate menstruation. Collectively, the questionnaire integrated demographic data, medical and family history, health behaviors, clinical symptoms, psychological status, and anthropometric measures to provide a comprehensive assessment of cardiovascular risk factors in the study population. 2.3. Statistical Analysis: The data were analyzed using the SPSS Statistical Package for Social Sciences version 25.0, showing numbers and percentages (for categorical variables), or averages and standard deviations (SD for continuous variables). 3. Results 3.1. Sample demographics: The study sample consisted of 252 students, 53.6% were male and 46.4% were female. students of medicine represented the largest proportion (31.3%), followed by dentistry (29%), engineering (18.3%), and pharmacy (12.7%). With respect to academic year, the distribution was relatively balanced: second- and fifth-year students each accounted for 21.8% of the sample, third-year students for 21.4%, fourth-year students for 17.1%, and first-year students for 15.1%, while sixth-year students constituted only 2.8%. In terms of marital status, the vast majority of students were single (98%). 3.2. Habits and lifestyle: 19% of students were current smokers. Alcohol consumption was rare, reported by only 4% of students. More than half considered themselves physically active, though only 38.9% engaged in heavy activity, compared with 83.3% who reported light activity such as walking or running; 40.9% were registered in a sports club. In terms of exercise frequency, 42.5% reported two to four days per week, 21% one day, 15.5% five to seven days, and 21% none at all. Exercise duration varied: 21% exercised 15 minutes or less, 19.8% for 30 minutes, 19.8% for one hour, 14.3% for more than an hour, while 25% did not exercise at all. Regarding diet, 63.9% consumed fast food occasionally, 15.1% frequently, and 21% never. 3.3. Health status: 21.4% had a first-degree and 40.9% a second-degree family history of CVD. More than half had never tested their blood sugar; among those tested, only 2.4% stated elevated values. Lipid testing was uncommon, 2.4% stated elevated values. Cardiac screening was limited: 16.7% had normal echocardiograms and 18.3% normal ECGs, while only 1.6% showed abnormalities; most had never been tested. Blood pressure was measured in most students, with 76.2% normal. Finally, 12.7% had visited the ER and 25% consulted a cardiologist, though the majority had not sought medical care. 3.4. Scanning for physical symptoms: Fatigue was the most notable symptom with 32.5% of students, followed by Headaches occurring in 29.8%. Chest pain was also reported by 6.3%. Dizziness affected 12.3% of students, while fatigue was more prevalent, noted by 32.5%. 3.5. Screening For Psychological Symptoms: 17.5% had sleep disturbances. Clinical depressive symptoms were present in 33.7% of students, and anxiety was also frequent, with 29.8% reporting stress or tension; only about one-fifth had no significant psychological symptoms. 3.6. Cardiac risk factors rate: The following variables were considered as cardiac risk factors: ( 1 ) positive history of cardiac disease, ( 2 ) positive family history, ( 3 ) smoking, ( 4 ) unhealthy diet, ( 5 ) obesity, ( 6 ) physical inactivity, ( 7 ) diabetes, ( 8 ) irregular menstrual cycle, ( 9 ) hyperlipidemia, ( 10 ) clinical depressive symptoms, ( 11 ) clinical anxiety symptoms, ( 12 ) sleep disturbance. Obesity was the most common risk factor in the study sample at 75%, followed by depressive symptoms and clinical anxiety symptoms, respectively. The sample was divided into three categories: ( 1 ) category without any risk factors, ( 2 ) category with a single risk factor, ( 2 ) category with two or more risk factors. Obesity (75%) and depression were the most common risk factors. Nearly 74% of the students have two or more cardiac risk factors. (Figs. 1 and 2). 4. Discussion The study revealed a notable clustering of cardiovascular risk factors among university students, including high rates of obesity (75%), considerable psychological burden from depression and anxiety, and mixed lifestyle habits, such as irregular physical activity and frequent fast-food consumption. These findings underscore the university years as a critical period for the development of behaviors that may contribute to future cardiovascular risk. Firstly, the reported obesity rate in this sample is high compared to aggregated rates for university students or medical students in previous studies; Large-scale reviews have reported much lower rates of obesity, although there has been a sustained global increase in overweight rates since the 1980s ( 4 , 5 ). This variation may reflect methodological factors (different BMI definitions, self-reported versus actual measurements), demographic factors, and environmental factors (availability of fast food). On the other hand, the clinical impact of obesity, particularly abdominal obesity, is clearly documented as an independent risk factor for hypertension, insulin resistance, diabetes, and lipid disorders, all of which are pathways to coronary artery disease and stroke ( 4 ). Therefore, the high prevalence of obesity in our sample suggests that universities should be considered as a target environment for early nutritional and environmental interventions. Furthermore, the prevalence of obesity in our study appeared higher than that reported among university students in some regional studies, ranging from 20% to 35% in studies conducted in Saudi Arabia and Jordan ( 5 , 6 ), indicating an increasing burden that warrants preventive intervention. Second, the study revealed a high prevalence of mental health disorders (depression ~ 33.7% and anxiety ~ 29.8%). These figures are consistent with systematic reviews indicating that university students are exposed to mental health disorders at high rates that vary between countries and measurement methodologies ( 7 ). The significance here extends beyond the narrow psychological dimension: recent evidence links chronic, low-grade disorders to inflammatory pathways, dysfunction in the hypothalamic-pituitary-adrenal axis, and impaired sympathetic/parasympathetic activity, which explains the association between depression and adverse cardiac outcomes independent of traditional factors ( 7 ). Furthermore, mental health disorders promote the adoption of risky behaviors (inactivity, increased consumption of processed foods, smoking), thus amplifying the cumulative risk. Third, there is a discrepancy in physical activity. Although more than half of the sample considered themselves \"active,\" data on the frequency and duration of exercise reveal that the actual adherence to public health recommendations (≥ 150 moderate minutes per week) may be lower—a pattern documented globally. International reports show declining levels of physical activity among young people and increasing sedentary behavior, a contributing factor to the rise of obesity and metabolic syndrome ( 8 , 9 ). This highlights the need for standardized measurements (IPAQ or field-based measurement tools) in follow-up studies, rather than relying solely on self-reporting. Fourth, the prevalence of smoking in this study was lower than in some regional university studies, but it remains significant for protection. Even moderate smoking rates among young people carry a substantial future burden on cardiovascular health, given the early effects of smoking on endothelial function, inflammation, and coagulation ( 10 ). Alcohol consumption was relatively low, reflecting cultural/behavioral factors that may differ from other societies and warrant contextual interpretations and caution in comparisons. Fifth, this study demonstrates a pattern of risk factor accumulation—where participants were grouped according to the number of factors—a useful practical indicator in public health practice. This aligns with the epidemiological concept of “risk accumulation,” which posits that continuous and repeated exposure to modifiable risk factors leads to cumulative biological damage over time, increasing the likelihood of subsequent chronic disease ( 11 , 12 ). Limitations : Regarding methodological limitations, it should be noted that the cross-sectional nature of the study precludes causal inferences, and self-reporting may be subject to social response and memory bias. Furthermore, the lack of standardized laboratory and methodological tests for each sample (lipids, glucose, and blood pressure) limits the ability to accurately assess certain biochemical risk factors. Additionally, the uneven representation of colleges and academic years may affect the generalizability of the results to the entire university student body; therefore, subsequent studies should be conducted using a stratified model, a nationally representative sample, or by converting this survey into a longitudinal follow-up program. 5. Conclusion This study focused on the accumulation of cardiovascular risk factors in young people. Early, multifaceted intervention has the potential to significantly reduce the future burden of cardiovascular disease. Periodic monitoring and longitudinal analysis methodologies will provide stronger evidence for evaluating the effectiveness of preventive measures and planning sustainable health policies. The findings call for the adoption of a multi-level university-wide preventive strategy: improving the food environment on campus (reducing the availability of high-calorie foods, increasing healthy options), implementing regular and simple physical activity programs, integrating accessible mental health services (counseling, support groups, and referrals), and launching anti-smoking awareness campaigns. It is also recommended to implement simple periodic screenings (measuring weight, waist circumference, blood pressure, and fasting blood sugar levels when needed) and link the results to individualized intervention strategies. Finally, we recommend converting the study to a longitudinal design to assess the impact of the interventions and measure changes in the risk factor accumulation index over time. Declarations Ethics approval and consent to participate: This study was approved by the Institutional Review Board (IRB) at SPU (Syrian Private University Institutional Review Board). Informed consent was obtained from every participant before participation. All procedures performed in studies involving human participants were following the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests. Funding: This project did not receive any funding from any agencies in the public, commercial, or non-profit sectors. Author Contribution All authors contributed extensively to the work presented in this paper. Yasser Kajjoun were responsible for the design of this study. Mhd Homam Safiah and Yasser Kajjoun were responsible for the literature search, data collection, and write-up. Marwan shameih supervised the study. All authors read and approved the final draft. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Zhang B, Luo W, Cai Y, Liu L, Ma X, Yang W, et al. Global burden of adolescent and young adult cardiovascular diseases and risk factors: Results from Global Burden of Disease Study 2019. Innov Med. 2024;2(2):100063. Zeitouni M, Clare RM, Chiswell K, Abdulrahim J, Shah N, Pagidipati NP, et al. Risk Factor Burden and Long-Term Prognosis of Patients With Premature Coronary Artery Disease. J Am Heart Assoc. 2020;9(24):e017712. Zeitouni M, Clare RM, Chiswell K, Abdulrahim J, Shah N, Pagidipati NP, et al. Risk Factor Burden and Long-Term Prognosis of Patients With Premature Coronary Artery Disease. J Am Heart Association. 2020;9(24):e017712. Celano CM, Daunis DJ, Lokko HN, Campbell KA, Huffman JC. Anxiety Disorders and Cardiovascular Disease. Curr Psychiatry Rep. 2016;18(11):101. 10.1007/s11920-016-0739-5 . PMID: 27671918; PMCID: PMC5149447. Powell-Wiley TM, Poirier P, Burke LE, et al. Obesity and cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2021;143(21):e984–1010. Al-Qahtani AM. Prevalence and predictors of obesity and overweight among university students in Abha, Saudi Arabia. Int J Environ Res Public Health. 2020;17(12):4472. Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res. 2013;47(3):391–400. Hare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression and cardiovascular disease: A clinical review. Eur Heart J. 2014;35(21):1365–72. Khalil S et al. Global prevalence of obesity and overweight among medical students: systematic review & meta-analysis. BMC Public Health. 2024. Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: A pooled analysis. Lancet Glob Health. 2018;6(10):e1077–86. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. 2014. Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: conceptual models. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Factors Among College Students In Syrian Private University- A Cross- Sectional Study\",\"fulltext\":[{\"header\":\"1. Background\",\"content\":\"\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eRecent figures shows that around six million of younger adults globally had Cardiovascular disease (CVD) reflecting public health emergency world-wide (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Premature Coronary Artery Disease (CAD), a major class od CVD, is now describe as the fastest epidemic with serious substantial portion of ten-years mortality on the long-term (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Although the concerning rates, CVD can be prevented by limiting the wide range of leading risk factors. American heart association noticed the failure of modifying cardiac risk factors among people with premature CAD (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe significance of examining cardiac risk factors among university students stems from the opportunity it provides for early intervention and disease prevention, as this stage of life is critical for establishing lifelong health behaviors. Such research also supports the development of targeted, evidence-based health education programs that enhance awareness among young adults, ultimately benefiting society at large. In addition, it offers valuable insights into the influence of behavioral, physiological, and social determinants on cardiovascular health, particularly in the context of contemporary challenges\\u0026mdash;such as psychological stress\\u0026mdash;that may contribute to an increased burden of risk factors.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\"},{\"header\":\"2. Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e2.1. Study design and Sampling:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eA cross-sectional survey was conducted between February and April 2025 using a convenience sampling approach among students at the Syrian Private University. Participation was voluntary, and written informed consent was obtained from all respondents. Students were assured that their answers would remain anonymous, that completion of all questions was not obligatory, and that they could withdraw from the survey at any time. Eligibility criteria included being a student at the Syrian Private University, aged 18 years or older. The study objectives were explained in writing and attached to the questionnaire. The required sample size was calculated to be 246 students, based on a total university population of 3,000, using a standard sample size calculator. Ethical approval for the study was obtained from the Institutional Review Board (IRB) of the Faculty of Medicine, Syrian Private University.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e2.2. Variables addressed in this research:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eA structured, self-administered questionnaire in Arabic was distributed to students at the Syrian Private University. The reliability of the instrument was confirmed with a Cronbach\\u0026rsquo;s alpha of 0.754. The questionnaire was designed to capture multiple dimensions of cardiovascular risk factors among university students. It collected information on sociodemographic characteristics, including gender, age, college, year of study, marital status, and place of residence. Medical and family history was assessed through questions on the presence of cardiovascular or metabolic conditions such as hypertension, diabetes, renal failure, and gout, in addition to the use of cardiac medications, family history of cardiac disease among first- and second-degree relatives, and details of prior medical examinations including blood glucose and lipid profile testing, echocardiogram, electrocardiogram, blood pressure measurements, and visits to either the emergency department or a cardiologist.\\u003c/p\\u003e\\u003cp\\u003eLifestyle and health behaviors were also evaluated, with items covering smoking, alcohol consumption, physical activity (type, intensity, duration, weekly frequency, and gym membership), and the frequency of fast-food intake. Symptoms and psychological factors were explored through questions on cardiac and general complaints such as palpitations, headache, shortness of breath, dizziness, and fatigue, as well as sleep disturbances, including insomnia and difficulty maintaining sleep. Standardized items were used to assess the severity and frequency of psychological disorders such as anxiety, stress, and depression. Anthropometric indicators were recorded in the form of weight and height, which were used to calculate body mass index (BMI) and assess abdominal obesity.\\u003c/p\\u003e\\u003cp\\u003eIn addition, a female-specific section was included to gather information on menstrual cycle characteristics, including regularity, the presence of polycystic ovary syndrome (PCOS), and the use of medications to regulate menstruation. Collectively, the questionnaire integrated demographic data, medical and family history, health behaviors, clinical symptoms, psychological status, and anthropometric measures to provide a comprehensive assessment of cardiovascular risk factors in the study population.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e2.3. Statistical Analysis:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eThe data were analyzed using the SPSS Statistical Package for Social Sciences version 25.0, showing numbers and percentages (for categorical variables), or averages and standard deviations (SD for continuous variables).\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"3. Results\",\"content\":\"\\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.1. Sample demographics:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eThe study sample consisted of 252 students, 53.6% were male and 46.4% were female. students of medicine represented the largest proportion (31.3%), followed by dentistry (29%), engineering (18.3%), and pharmacy (12.7%). With respect to academic year, the distribution was relatively balanced: second- and fifth-year students each accounted for 21.8% of the sample, third-year students for 21.4%, fourth-year students for 17.1%, and first-year students for 15.1%, while sixth-year students constituted only 2.8%. In terms of marital status, the vast majority of students were single (98%).\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.2. Habits and lifestyle:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e19% of students were current smokers. Alcohol consumption was rare, reported by only 4% of students. More than half considered themselves physically active, though only 38.9% engaged in heavy activity, compared with 83.3% who reported light activity such as walking or running; 40.9% were registered in a sports club. In terms of exercise frequency, 42.5% reported two to four days per week, 21% one day, 15.5% five to seven days, and 21% none at all. Exercise duration varied: 21% exercised 15 minutes or less, 19.8% for 30 minutes, 19.8% for one hour, 14.3% for more than an hour, while 25% did not exercise at all. Regarding diet, 63.9% consumed fast food occasionally, 15.1% frequently, and 21% never.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.3. Health status:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e21.4% had a first-degree and 40.9% a second-degree family history of CVD. More than half had never tested their blood sugar; among those tested, only 2.4% stated elevated values. Lipid testing was uncommon, 2.4% stated elevated values. Cardiac screening was limited: 16.7% had normal echocardiograms and 18.3% normal ECGs, while only 1.6% showed abnormalities; most had never been tested. Blood pressure was measured in most students, with 76.2% normal. Finally, 12.7% had visited the ER and 25% consulted a cardiologist, though the majority had not sought medical care.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.4. Scanning for physical symptoms:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eFatigue was the most notable symptom with 32.5% of students, followed by Headaches occurring in 29.8%. Chest pain was also reported by 6.3%. Dizziness affected 12.3% of students, while fatigue was more prevalent, noted by 32.5%.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.5. Screening For Psychological Symptoms:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e17.5% had sleep disturbances. Clinical depressive symptoms were present in 33.7% of students, and anxiety was also frequent, with 29.8% reporting stress or tension; only about one-fifth had no significant psychological symptoms.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003e3.6. Cardiac risk factors rate:\\u003c/h2\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eThe following variables were considered as cardiac risk factors: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) positive history of cardiac disease, (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) positive family history, (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) smoking, (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) unhealthy diet, (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e) obesity, (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e) physical inactivity, (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e) diabetes, (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e) irregular menstrual cycle, (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e) hyperlipidemia, (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e) clinical depressive symptoms, (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e) clinical anxiety symptoms, (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e) sleep disturbance. Obesity was the most common risk factor in the study sample at 75%, followed by depressive symptoms and clinical anxiety symptoms, respectively. The sample was divided into three categories: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) category without any risk factors, (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) category with a single risk factor, (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) category with two or more risk factors. Obesity (75%) and depression were the most common risk factors. Nearly 74% of the students have two or more cardiac risk factors. (Figs.\\u0026nbsp;1 and 2).\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eThe study revealed a notable clustering of cardiovascular risk factors among university students, including high rates of obesity (75%), considerable psychological burden from depression and anxiety, and mixed lifestyle habits, such as irregular physical activity and frequent fast-food consumption. These findings underscore the university years as a critical period for the development of behaviors that may contribute to future cardiovascular risk.\\u003c/p\\u003e\\u003cp\\u003eFirstly, the reported obesity rate in this sample is high compared to aggregated rates for university students or medical students in previous studies; Large-scale reviews have reported much lower rates of obesity, although there has been a sustained global increase in overweight rates since the 1980s (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). This variation may reflect methodological factors (different BMI definitions, self-reported versus actual measurements), demographic factors, and environmental factors (availability of fast food). On the other hand, the clinical impact of obesity, particularly abdominal obesity, is clearly documented as an independent risk factor for hypertension, insulin resistance, diabetes, and lipid disorders, all of which are pathways to coronary artery disease and stroke (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Therefore, the high prevalence of obesity in our sample suggests that universities should be considered as a target environment for early nutritional and environmental interventions. Furthermore, the prevalence of obesity in our study appeared higher than that reported among university students in some regional studies, ranging from 20% to 35% in studies conducted in Saudi Arabia and Jordan (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e), indicating an increasing burden that warrants preventive intervention.\\u003c/p\\u003e\\u003cp\\u003eSecond, the study revealed a high prevalence of mental health disorders (depression\\u0026thinsp;~\\u0026thinsp;33.7% and anxiety\\u0026thinsp;~\\u0026thinsp;29.8%). These figures are consistent with systematic reviews indicating that university students are exposed to mental health disorders at high rates that vary between countries and measurement methodologies (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). The significance here extends beyond the narrow psychological dimension: recent evidence links chronic, low-grade disorders to inflammatory pathways, dysfunction in the hypothalamic-pituitary-adrenal axis, and impaired sympathetic/parasympathetic activity, which explains the association between depression and adverse cardiac outcomes independent of traditional factors (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). Furthermore, mental health disorders promote the adoption of risky behaviors (inactivity, increased consumption of processed foods, smoking), thus amplifying the cumulative risk.\\u003c/p\\u003e\\u003cp\\u003eThird, there is a discrepancy in physical activity. Although more than half of the sample considered themselves \\\"active,\\\" data on the frequency and duration of exercise reveal that the actual adherence to public health recommendations (\\u0026ge;\\u0026thinsp;150 moderate minutes per week) may be lower\\u0026mdash;a pattern documented globally. International reports show declining levels of physical activity among young people and increasing sedentary behavior, a contributing factor to the rise of obesity and metabolic syndrome (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). This highlights the need for standardized measurements (IPAQ or field-based measurement tools) in follow-up studies, rather than relying solely on self-reporting.\\u003c/p\\u003e\\u003cp\\u003eFourth, the prevalence of smoking in this study was lower than in some regional university studies, but it remains significant for protection. Even moderate smoking rates among young people carry a substantial future burden on cardiovascular health, given the early effects of smoking on endothelial function, inflammation, and coagulation (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Alcohol consumption was relatively low, reflecting cultural/behavioral factors that may differ from other societies and warrant contextual interpretations and caution in comparisons.\\u003c/p\\u003e\\u003cp\\u003eFifth, this study demonstrates a pattern of risk factor accumulation\\u0026mdash;where participants were grouped according to the number of factors\\u0026mdash;a useful practical indicator in public health practice. This aligns with the epidemiological concept of \\u0026ldquo;risk accumulation,\\u0026rdquo; which posits that continuous and repeated exposure to modifiable risk factors leads to cumulative biological damage over time, increasing the likelihood of subsequent chronic disease (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eLimitations\\u003c/b\\u003e:\\u003c/p\\u003e\\u003cp\\u003eRegarding methodological limitations, it should be noted that the cross-sectional nature of the study precludes causal inferences, and self-reporting may be subject to social response and memory bias. Furthermore, the lack of standardized laboratory and methodological tests for each sample (lipids, glucose, and blood pressure) limits the ability to accurately assess certain biochemical risk factors. Additionally, the uneven representation of colleges and academic years may affect the generalizability of the results to the entire university student body; therefore, subsequent studies should be conducted using a stratified model, a nationally representative sample, or by converting this survey into a longitudinal follow-up program.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\"},{\"header\":\"5. Conclusion\",\"content\":\"\\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eThis study focused on the accumulation of cardiovascular risk factors in young people. Early, multifaceted intervention has the potential to significantly reduce the future burden of cardiovascular disease. Periodic monitoring and longitudinal analysis methodologies will provide stronger evidence for evaluating the effectiveness of preventive measures and planning sustainable health policies. The findings call for the adoption of a multi-level university-wide preventive strategy: improving the food environment on campus (reducing the availability of high-calorie foods, increasing healthy options), implementing regular and simple physical activity programs, integrating accessible mental health services (counseling, support groups, and referrals), and launching anti-smoking awareness campaigns. It is also recommended to implement simple periodic screenings (measuring weight, waist circumference, blood pressure, and fasting blood sugar levels when needed) and link the results to individualized intervention strategies. Finally, we recommend converting the study to a longitudinal design to assess the impact of the interventions and measure changes in the risk factor accumulation index over time.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate:\\u003c/strong\\u003e\\u003cp\\u003e This study was approved by the Institutional Review Board (IRB) at SPU (Syrian Private University Institutional Review Board). Informed consent was obtained from every participant before participation. All procedures performed in studies involving human participants were following the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication:\\u003c/strong\\u003e\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003ch2\\u003eCompeting interests:\\u003c/h2\\u003e\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\u003c/p\\u003e\\u003ch2\\u003eFunding:\\u003c/h2\\u003e\\u003cp\\u003eThis project did not receive any funding from any agencies in the public, commercial, or non-profit sectors.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eAll authors contributed extensively to the work presented in this paper. Yasser Kajjoun were responsible for the design of this study. Mhd Homam Safiah and Yasser Kajjoun were responsible for the literature search, data collection, and write-up. Marwan shameih supervised the study. All authors read and approved the final draft.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eZhang B, Luo W, Cai Y, Liu L, Ma X, Yang W, et al. Global burden of adolescent and young adult cardiovascular diseases and risk factors: Results from Global Burden of Disease Study 2019. Innov Med. 2024;2(2):100063.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eZeitouni M, Clare RM, Chiswell K, Abdulrahim J, Shah N, Pagidipati NP, et al. Risk Factor Burden and Long-Term Prognosis of Patients With Premature Coronary Artery Disease. J Am Heart Assoc. 2020;9(24):e017712.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eZeitouni M, Clare RM, Chiswell K, Abdulrahim J, Shah N, Pagidipati NP, et al. Risk Factor Burden and Long-Term Prognosis of Patients With Premature Coronary Artery Disease. J Am Heart Association. 2020;9(24):e017712.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eCelano CM, Daunis DJ, Lokko HN, Campbell KA, Huffman JC. Anxiety Disorders and Cardiovascular Disease. Curr Psychiatry Rep. 2016;18(11):101. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/s11920-016-0739-5\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s11920-016-0739-5\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 27671918; PMCID: PMC5149447.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003ePowell-Wiley TM, Poirier P, Burke LE, et al. Obesity and cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2021;143(21):e984\\u0026ndash;1010.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAl-Qahtani AM. Prevalence and predictors of obesity and overweight among university students in Abha, Saudi Arabia. Int J Environ Res Public Health. 2020;17(12):4472.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eIbrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res. 2013;47(3):391\\u0026ndash;400.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression and cardiovascular disease: A clinical review. Eur Heart J. 2014;35(21):1365\\u0026ndash;72.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKhalil S et al. Global prevalence of obesity and overweight among medical students: systematic review \\u0026amp; meta-analysis. BMC Public Health. 2024.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGuthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: A pooled analysis. Lancet Glob Health. 2018;6(10):e1077\\u0026ndash;86.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eU.S. Department of Health and Human Services. The Health Consequences of Smoking\\u0026mdash;50 Years of Progress: A Report of the Surgeon General. 2014.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eBen-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: conceptual models.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"CVD, Premature CAD, Cardiac Risk factors\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8041576/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8041576/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e\\u003cp\\u003eAssessing cardiovascular risk factors among university students is important as it allows for early intervention and prevention of future diseases. This study aimed to assess the prevalence of cardiovascular risk factors among students at the Syrian Private University.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e\\u003cp\\u003eThis cross-sectional study was conducted in 2025 using a convenience sampling among students of the Syrian Private University. A self-administered questionnaire in Arabic was distributed to the students. Data were coded and entered into a computer, then analyzed using the Statistical Package for the Social Sciences.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003eThe study sample consisted of 252 students, with 53.6% male and 46.4% female. Medical students constituted the largest proportion (31.3%), followed by dental students (29%). Current smoking prevalence was 19%. Low physical activity was reported by 43.3%, and 63.9% reported consuming fast food. Sleep disturbances were present in 17.5% of participants. Depressive symptoms were identified in nearly one-third of students (33.7%), while anxiety was reported by 29.8%. Stress was highly prevalent, affecting 81.3% of the students. Overall, 74% of participants had at least two cardiovascular risk factors.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e\\u003cp\\u003eThis study highlights the clustering of cardiovascular risk factors among young adults, particularly obesity and psychological disorders. Early and multidimensional interventions may have a significant impact on reducing the future burden of cardiovascular diseases.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Assessing Cardiovascular Risk Factors Among College Students In Syrian Private University- A Cross- Sectional Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-11-10 16:23:23\",\"doi\":\"10.21203/rs.3.rs-8041576/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"b1f2b8a3-d8c0-4485-a1f7-89e8c1b7d21e\",\"owner\":[],\"postedDate\":\"November 10th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-11-20T06:23:12+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-11-10 16:23:23\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8041576\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8041576\",\"identity\":\"rs-8041576\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}