Cardiovascular risk factors predict survival in middle-aged men during 50 years

The L-shaped association of mid-upper arm circumference with all-cause and cause-specific mortality in US adults: a population-based prospective cohort study

BACKGROUND

The arm circumference is a feasible and reliable indicator in evaluating the nutritional status of children. However, its application in general adults has yet to be thoroughly investigated.

OBJECTIVE

This study aimed to evaluate the association between mid-upper arm circumferences (MUACs) and mortality in general adults.

METHODS

The nationally representative cohort from the National Health and Nutrition Examination Survey (1999-2018) was analyzed with mortality information obtained through linkage to the National Death Index. The baseline MUACs were collected as exposure. Survey-weighted Cox proportional hazard regressions were performed to estimate the hazard ratios (HRs) and 95% confidential intervals (CIs) of mortality risk for individuals with different MUACs. Restricted cubic spline analyses were performed to examine the nonlinear association of MUAC with all-cause and cause-specific mortality.

RESULTS

A total of 52,159 participants were included in this study. During a median follow-up time of 117 months, 7157 deaths were documented, with leading causes of cardiovascular disease (CVD), cancer, and respiratory disease. Individuals in the first quartile (Q1) of MUAC tended to have higher all-cause mortality risk than the rest after full adjustment. Similarly, CVD mortality risk in Q1 was higher than that in the second quartile (Q2) and the third quartile (Q3); respiratory mortality risk in Q1 was higher than in Q2. MUAC was non-linearly associated with all-cause mortality and CVD mortality. Individuals in Q1 MUAC (≤ 29.3) tended to have higher all-cause mortality risk, with HRs (95% CIs) estimated to be 0.76 (0.67-0.87) for Q2 (29.4, 32.5), 0.69 (0.59-0.81) for Q3 (32.6, 36.0), and 0.59 (0.46-0.75) for Q4 (≥ 36.1) after adjustment of demographic, lifestyle, and comorbidity covariates. Similarly, compared with Q1, HRs (95% CIs) for CVD mortality were estimated to be 0.73 (0.58-0.93) for Q2 and 0.57 (0.43-0.47) for Q3; HRs (95% CIs) for respiratory mortality was estimated to be 0.57 (95% CI, 0.37-0.87) for Q2 with other differences not significant.

CONCLUSION

The MUAC was inversely associated with long-term mortality in general adults in the United States and may serve as a valuable measurement in adult health evaluations.

Cardiovascular risk factors predict age at death in 60-year follow-up of the Seven Countries Study

OBJECTIVES

To study age at death (AD) and its determinants in cohorts of middle-aged men followed-up until extinction.

MATERIAL AND METHODS

A total of 9063 middle-aged men enrolled in 10 cohorts of 6 countries (USA, Finland, the Netherlands, Italy, Greece and Japan) within the Seven Countries Study were examined and then followed up for 60 years until extinction. AD was computed and a small number of risk factors were tested through multiple linear regression as possibly related to attained AD.

RESULTS

AD ranged across cohorts from 71.8 years in East Finland and 80.5 years in Crete with levels roughly lower in the USA and Northern Europe and higher elsewhere. Across cohorts, the correlation coefficients of systolic blood pressure (R = -0.58) and of CVD prevalence (R = -0.65) versus average AD were the only significant ones. At the individual level in the pool of all cohorts, a multiple linear regression model showed that age, vigorous physical activity, never and ex-smokers were favorably related to AD, while the reverse was true for systolic blood pressure, heart rate, serum cholesterol, CVD prevalence and silent ECG abnormalities. BMI had a parabolic relationship with AD. The predicting power of single risk factors, expressed in years gained or lost, was relatively small, but arbitrary combinations of several of them produced large differences in AD.

CONCLUSIONS

A small number of CVD risk factors were strongly associated with AD in a life-long follow-up.

Determinants of longevity and age at death in a practically extinct cohort of middle-aged men followed-up for 61 years

OBJECTIVES

To explore possible determinants of longevity as a function of many personal characteristics in a cohort of middle-aged men followed-up until practical extinction.

MATERIALS AND METHODS

In the Italian Rural Area of the Seven Countries Study, 1712 men aged 40-59 were examined in 1960 and 35 personal characteristics were measured. The subsequent follow-up for life status was of 61 years when only 3 men survived. A Kaplan-Meier curve was computed. A Cox model was solved with all-cause mortality as end-point and 35 potential determinants as covariates. A Multiple Linear Regression (MLR) model was also solved with the same covariates and age at death (AD) as end-point.

RESULTS

After 61 years, 99.8% of men had died and median age at death was 75. Beneficial risk factors for both models (p < 0.05) were: never smoker, vigorous physical activity, prudent and Mediterranean diets, arm circumference, subscapular skinfold, and vital capacity. Adverse risk factors (p < 0.05) were: mother early death, laterality/linearity index, systolic blood pressure, serum cholesterol, corneal arcus, xanthelasma, cardiovascular diseases, cancer, diabetes, and chronic bronchitis. Some arbitrary combinations of selected risk factors were used to estimate AD as a function of coefficients of the MLR, showing large differences up to 10 years or more.

CONCLUSIONS

Several personal characteristics of anthropometric, behavioral, biophysical, biochemical, and clinical nature are strongly associated with longevity when measured in middle-aged men and then followed up until extinction.

How the Seven Countries Study contributed to the launch and development of cardiovascular epidemiology in Italy. A historical perspective

The Italian research group of the Seven Countries Study of Cardiovascular Diseases (SCS), through the independent use of the national cohorts and data, had the lucky opportunity, starting in the early 1960, to launch the Italian research in epidemiology of cardiovascular diseases (CVD). In this way, the Italian Section of that international study became the first investigation with baseline measurements in various cohorts, subsequent re-examinations, systematic search for morbid events, and follow-up for mortality up to 50 years. A large number of scientific aspects has been tackled including estimates of morbidity and mortality rates, the association of risk factors with cardiovascular events and total mortality, the role of risk factor changes, the use of multivariable models, the role of lifestyle behavior, the determinants of all-cause mortality including risk factors rarely measured in other studies, the identification of characteristics of a condition called Heart Disease of Uncertain Etiology (HDUE), the production of predictive tools for practical use and several other issues. All this has been enhanced by the availability of extremely long follow-up data rarely found in other studies. Field work organization, measurement techniques, diagnostic criteria, data handling and computing had the limitations and difficulties typical of those times, the mid of last century, when CVD epidemiology was at its beginning. All this represented anyhow the start of CVD epidemiology research in the country and was the stimulus to the start of other studies and a valuable collaboration with some of them.

Impact of Sex on Office White Coat Effect Tail: Investigating Two Italian Residential Cohorts

To assess the impact of sex on office white-coat effect tail (OWCET), the waning of systolic blood pressure (SBP) after its waxing during office visit, on the incidence of long-term major fatal and non-fatal events in two Italian residential cohorts [from the Gubbio Study and the Italian Rural Areas of the Seven Countries Study (IRA)]. There were 3565 persons (92 with missing data, 44% men, 54 ± 11 years) included in the Gubbio and 1712 men (49 ± 5 years) in the IRA studies. OWCET was defined as a decrease of ≥10 mmHg in SBP between successive measurements with slight measurement differences between the two cohorts. Cardiovascular (CVD), coronary heart disease (CHD) and stroke (STR) incidences were considered. Over an approximately 20-year follow-up, women with OWCET had an increased risk of CVD [HR: 1.591 (95%CI: 1.204–2.103)], CHD [HR: 1.614 (95%CI: 1.037–2.512)] and STR [HR: 1.696 (95%CI: 1.123–2.563)] events independently of age, serum and HDL cholesterol, cigarettes, BMI and SBP in the Gubbio study. However, there was no increased risk of CVD, CHD or STR in men with OWCET neither in the Gubbio 20-year follow-up nor in the IRA 50-year follow-up. These results were not modified significantly by the correction of the regression dilutions bias between the first and the subsequent SBP measurements. Thus, in primary care, OWCET should be actively evaluated in women as it can improve stratification of long-term CVD, CHD and STR risks.

Age at death in cohorts of middle-aged men followed-up until nearly extinction: the European areas of the Seven Countries Study

OBJECTIVES

To describe age at death (AD) in ten cohorts of middle-aged men followed-up until nearly extinction as a function of personal characteristics measured at baseline.

MATERIAL AND METHODS

Cohorts of men aged 40-59 years in five European countries (Finland, the Netherlands, Italy, Serbia, Greece) were examined and then followed-up for mortality during 45 (3 cohorts) or 50 years (7 cohorts). Multiple linear regression (MLR) models were computed with AD as dependent variable and 35 personal characteristics as independent variables.

RESULTS

Out of 7047 men, 6798 (96.5%) died in 45-50 years. Average AD was 74.4 (median 75) years. Only five variables were significant in all the five countries when tested by MLR. By pooling together all countries and selecting variables by a stepwise technique, 20 were significant (p < .05): age at entry examination, being married, being a never smoker or an ex-smoker (versus current smokers), forced expiratory volume, high socio-economic status, arm circumference, subscapular skinfold, having moderate or vigorous physical activity (all with a positive relationship with AD); father early mortality, laterality/linearity index, high systolic blood pressure, high serum cholesterol, having a major cardiovascular disease, diabetes or chronic bronchitis (these with a negative relationship), while body mass index, subdivided into four classes, showed a parabolic relationship (versus a reference class). Each factor was associated with a difference of months or a few years to AD, while their combinations were associated with several years of greater or smaller AD.

CONCLUSIONS

The availability of a relatively small number of risk factors measured in middle-aged men allows making rough estimates of AD as related to all-cause mortality during a follow-up of 50 years. AD is also a valuable metrics to describe past health in nearly extinct populations. Key messages We aimed at studying the age at death (AD) of middle-aged men of the European cohorts of the Seven Countries Study, followed-up 45-50 years until nearly extinction, as a function of personal characteristics measured at baseline. Multiple linear regression (MLR) models were computed with AD as dependent variable and 35 personal characteristics or risk factors as independent variables and only five were significant in all individual countries, whereas pooling together all countries, 20 variables were significant as selected by stepwise MLR. Each factor was associated with differences of months or a few years to AD, while their combinations were associated with several years of greater or smaller AD. AD is a valuable metrics to describe past health in nearly extinct populations: it might also be used to communicate years of life gained by preventive measures on modifiable variables.

The influence of diet on anti-cancer immune responsiveness

Immunotherapy has matured into standard treatment for several cancers, but much remains to be done to extend the reach of its effectiveness particularly to cancers that are resistant within each indication. This review proposes that nutrition can affect and potentially enhance the immune response against cancer. The general mechanisms that link nutritional principles to immune function and may influence the effectiveness of anticancer immunotherapy are examined. This represents also the premise for a research project aimed at identifying the best diet for immunotherapy enhancement against tumours (D.I.E.T project). Particular attention is turned to the gut microbiota and the impact of its composition on the immune system. Also, the dietary patterns effecting immune function are discussed including the value of adhering to a healthy diets such as the Mediterranean, Veg, Japanese, or a Microbiota-regulating diet, the very low ketogenic diet, which have been demonstrated to lower the risk of developing several cancers and reduce the mortality associated with them. Finally, supplements, as omega-3 and polyphenols, are discussed as potential approaches that could benefit healthy dietary and lifestyle habits in the context of immunotherapy.

Mid-Arm Circumference and All-Cause, Cardiovascular, and Cancer Mortality among Obese and Non-Obese US Adults: the National Health and Nutrition Examination Survey III

Epidemiological studies have shown that mid-arm circumference (MAC) can be used to predict death risk and malnutrition. We performed a retrospective observational study involving 11,958 US participants aged 20–90 years from the National Health and Nutrition Examination Survey III, 1988–1994, to determine the correlation between MAC and all-cause, cardiovascular, and cancer mortality risk in the obese and non-obese population. Death certificate data were obtained up to 2006. The participants were divided into three groups on the basis of body mass index: 19 ≤ BMI < 25 kg/m² (normal weight group), 25 ≤ BMI < 30 kg/m² (overweight group) and BMI ≥ 30 kg/m² (obesity group); each group was then divided into three subgroups depending on their MAC level. In the non-obese population, MAC was inversely associated with all-cause mortality; specifically, in the normal weight group, the multivariate-adjusted hazard ratio of the T3 (29.6–42.0) cm subgroup was 0.72 (95% confidence interval: 0.58–0.90) when compared with the T1 (18.0–27.2) cm, while the multivariate-adjusted hazard ratio of the T2 (27.3–29.5) cm subgroup was 0.76 (95% confidence interval: 0.64–0.91) when compared with the T1 (18.0–27.2) cm subgroup. The results indicate that MAC is inversely associated with all-cause mortality in non-obese individuals in the United States.

Sitosterolemia: a review and update of pathophysiology, clinical spectrum, diagnosis, and management

Sitosterolemia is an autosomal recessive disorder characterized by increased plant sterol levels, xanthomas, and accelerated atherosclerosis. Although it was originally reported in patients with normolipemic xanthomas, severe hypercholesterolemia have been reported in patients with sitosterolemia, especially in children. Sitosterolemia is caused by increased intestinal absorption and decreased biliary excretion of sterols resulting from biallelic mutations in either ABCG5 or ABCG8, which encode the sterol efflux transporter ABCG5 and ABCG8. Patients with sitosterolemia show extreme phenotypic heterogeneity, ranging from almost asymptomatic individuals to those with severe hypercholesterolemia leading to accelerated atherosclerosis and premature cardiac death. Hematologic manifestations include hemolytic anemia with stomatocytosis, macrothrombocytopenia, splenomegaly, and abnormal bleeding. The mainstay of therapy includes dietary restriction of both cholesterol and plant sterols and the sterol absorption inhibitor, ezetimibe. Foods rich in plant sterols include vegetable oils, wheat germs, nuts, seeds, avocado, shortening, margarine and chocolate. Hypercholesterolemia in patients with sitosterolemia is dramatically responsive to low cholesterol diet and bile acid sequestrants. Plant sterol assay should be performed in patients with normocholesterolemic xanthomas, hypercholesterolemia with unexpectedly good response to dietary modifications or to cholesterol absorption inhibitors, or hypercholesterolemia with poor response to statins, or those with unexplained hemolytic anemia and macrothrombocytopenia. Because prognosis can be improved by proper management, it is important to find these patients out and diagnose correctly. This review article aimed to summarize recent publications on sitosterolemia, and to suggest clinical indications for plant sterol assay.

Cardiovascular and other causes of death as a function of lifestyle habits in a quasi extinct middle-aged male population. A 50-year follow-up study

OBJECTIVES

To relate major causes of death with lifestyle habits in an almost extinct male middle-aged population.

MATERIAL AND METHODS

A 40-59 aged male population of 1712 subjects was examined and followed-up for 50 years. Baseline smoking habits, working physical activity and dietary habits were related to 50 years mortality subdivided into 12 simple and 3 composite causes of death by Cox proportional hazard models. Duration of survival was related to the same characteristics by a multiple linear regression model.

RESULTS

Death rate in 50 years was of 97.5%. Out of 12 simple groups of causes of death, 6 were related to smoking habits, 3 to physical activity and 4 to dietary habits. Among composite groups of causes of death, hazard ratios (and their 95% confidence limits) of never smokers versus smokers were 0.68 (0.57-0.81) for major cardiovascular diseases; 0.65 (0.52-0.81) for all cancers; and 0.72 (0.64-0.81) for all-cause deaths. Hazard ratios of vigorous physical activity at work versus sedentary physical activity were 0.63 (0.49-0.80) for major cardiovascular diseases; 1.01 (0.72-1.41) for all cancers; and 0.76 (0.64-0.90) for all-cause deaths. Hazard ratios of Mediterranean Diet versus non-Mediterranean Diet were 0.68 (0.54-0.86) for major cardiovascular diseases; 0.54 (0.40-0.73) for all cancers; and 0.67 (0.57-0.78) for all-cause deaths. Expectancy of life was 12 years longer for men with the 3 best behaviors than for those with the 3 worst behaviors.

CONCLUSIONS

Some lifestyle habits are strongly related to lifetime mortality.

Lifestyle behaviour and lifetime incidence of heart diseases

OBJECTIVES

Investigate the relationship of some behavioural characteristics of a male population with lifetime incidence of heart diseases.

MATERIAL AND METHODS

In the Italian Rural Areas of the Seven Countries Study of Cardiovascular Diseases, 1677 heart disease-free men aged 40-59 years were followed up during 50 years for lifetime incidence of heart disease up to the age of 90 years. They were classified as coronary heart disease (CHD) and heart diseases of uncertain etiology (HDUE). Baseline cigarette smoking habits (non-smokers and ex-smokers, moderate smokers, heavy smokers), physical activity (sedentary, moderate, vigorous) and eating habits (non-Mediterranean Diet, Prudent Diet and Mediterranean Diet) were related to incidence of heart disease.

RESULTS

Incidence of CHD and HDUE up to the age of 90 years was 28.8 and 17.7%, respectively. Univariate and multivariate analyses showed strong association of behavioural characteristics with CHD incidence, but not with HDUE incidence. Cox proportional hazard rates for CHD were 1.45 (95% confidence intervals, CI: 1.11-1.90) for heavy smokers versus non-smokers; 0.67 (CI 0.50-0.89) for vigorous activity versus sedentary habits and 0.62 (CI 0.47-0.83) for Mediterranean Diet versus non-Mediterranean Diet. Combining CHD cases with HDUE cases made the predictive picture similar to that of CHD. When some basic risk factors were added to the model results remained substantially unaltered, despite the existence of some correlations of behaviours with risk factors.

CONCLUSIONS

Behavioural factors including cigarette smoking, physical activity and diet are strong predictors of lifetime incidence of common heart diseases even adding other traditional risk factors.

Xanthomas: clinical and pathophysiological relations

BACKGROUND

Xanthomas are well circumscribed lesions in the connective tissue of the skin, tendons or fasciae that predominantly consist of foam cells; these specific cells are formed from macrophages as a result of an excessive uptake of low density lipoprotein (LDL) particles and their oxidative modification.

RESULTS

Until recently, xanthelasma was considered to be only a cosmetic lesion; however, according to the results of recent prospective studies it is connected with an increased cardiovascular risk and reduced average lifespan. Pathogenetic mechanisms involved in the development of xanthomas resemble early stages of atherogenesis. In clinical practice, xanthomas can signalise various congenital or acquired dyslipidemias. The most prevalent form of xanthomas is xanthelasma palpebrarum. Tendinous and tuberous xanthomas are typical for autosomal dominant hypercholesterolemia, as well as for some rare conditions, such as cerebrotendinous xanthomatosis and familial β-sitosterolemia. In patients with familial hypercholesterolemia, the presence of tendinous xanthomas has been shown to be associated with a two to four times higher risk for cardiovascular disease. Eruptive xanthomas are skin manifestations of a severe hypertriglyceridemia and implicate an elevated risk for acute pancreatitis or type 2 diabetes mellitus. Xanthoma striatum palmare is pathognomic for primary dysbetalipoproteinemia, whereas diffuse plane xanthomas are frequently associated with paraproteinemia and lymphoproliferative disorders.

CONCLUSION

Thorough familiarity with the clinical presentation of xanthomas helps in the diagnosis and follow-up of different forms of dyslipidemia. Moreover, xanthelasma palpebrarum, the most prevalent form of xanthomas, is connected with increased risk of atherothrombotic disease independently of conventional cardiovascular risk factors. To fully understand the pathogenesis, further experimental and clinical research is required.

A prospective study of arm circumference and risk of death in Bangladesh

BACKGROUND

Epidemiological studies have observed protective effects of mid-upper arm circumference (MUAC) against all-cause mortality mostly in Western populations. However, evidence on cause-specific mortality is limited.

METHODS

The sample included 19 575 adults from a population-based cohort study in rural Bangladesh, who were followed up for an average of 7.9 years for mortality. Cox proportional hazards regression was used to evaluate the effect of MUAC, as well as the joint effect of body mass index (BMI) and MUAC, on the risk of death from any cause, cancer and cardiovascular disease (CVD).

RESULTS

During 154 664 person-years of follow-up, 744 deaths including 312 deaths due to CVD and 125 deaths due to cancer were observed. There was a linear inverse relationship of MUAC with total and CVD mortality. Each 1-cm increase in MUAC was associated a reduced risk of death from any cause [hazard ratio (HR) = 0.85; 95% confidence interval (C), 0.81-0.89) and CVD (HR = 0.87; 95% CI, 0.80-0.94), after controlling for potential confounders. No apparent relationship between MUAC and the risk of death from cancer was observed. Among individuals with a low BMI (<18.5 kg/m(2)), a MUAC less than 24 cm was associated with increased risk for all-cause (HR = 1.81; 95% CI, 1.52-2.17) and CVD mortality (HR = 1.45; 95% CI, 1.11-1.91).

CONCLUSIONS

MUAC may play a critical role on all-cause and CVD mortality in lean Asians.

Lifestyle habits and mortality from all and specific causes of death: 40-year follow-up in the Italian Rural Areas of the Seven Countries Study

OBJECTIVES

Three lifestyle factors were investigated in a population study to explore their relationships with a long-term mortality.

MATERIAL AND METHODS

In a cohort of 1564 men aged 45-64 and examined in 1965 within the Italian Rural Areas of the Seven Countries Study, smoking habits, physical activity at work and eating habits (as derived from factor analysis) were determined. During the follow-up 693 men died in 20 years and 1441 in 40 years.

RESULTS

In Cox proportional hazards models men smoking cigarettes (versus never smokers), those having a sedentary activity (versus the very active) and those following the Diet Score 1, indexing an unhealthy Diet (versus men with a Diet close to the healthy Mediterranean style) had highly significant hazards ratios (HR) in relations with 20- and 40-year mortality from all causes, coronary heart disease (CHD), cardiovascular disease (CVD) and cancer. HR for all causes in 40 years were 1.44 (95% confidence intervals, CI, 1.27 and 1.64) for smokers, 1.43 (CI 1.23 and 1.67) for sedentary people, and 1.31 (CI 1.15 and 1.50) for men with unhealthy diet. Larger HR were found for CHD, CVD and cancers deaths. Combination of 3 unhealthy risk factors versus their absence was associated with 4.8-year life loss in the 20-year follow-up and 10.7-year in the 40-year follow-up.

CONCLUSIONS

Lifestyle behavior linked to physical activity and smoking and eating habits is strongly associated with mortality and survival in middle aged men during long-term follow-up.

Increased predictive ability of BMI but not other risk factors with time in men: 39-year follow-up of total mortality in the Oslo Study

OBJECTIVE

Risk factor associations to mortality may change, in part due to removal of high-risk persons. We compared strengths of association and ability of risk factors to predict total mortality across short (<15 years), medium (15-29 years) and long (30-39 years) follow-up.

METHODS

Cardiovascular risk factors were measured in 1972-1973 in the Oslo Study among 14,846 men born in 1923-1932. Relationships of risk factors to mortality (to 2011) were analyzed using Cox regression models, and receiver operating characteristics (ROC) were estimated.

RESULTS

BMI was the only factor that increased strength of association with elapsed time (hazard ratio for ≥35 kg/m(2) vs. 22.5-24.9 kg/m(2): 1.25 (95% CI 0.73-2.17), 1.51 (95% CI 1.06-2.16) and 3.73 (95% CI 2.33-5.98) for <15, 15-29 and 30-39 years, respectively). Other factors lost predictive ability with time. Cigarette smoking was the strongest predictor in all periods. Serum lipids and systolic blood pressure increased risk in most periods, and moderate physical activity was protective to 29 years, but these factors and BMI contributed minimally to ROC.

DISCUSSION

Risk factors differed in association strengths and ability to predict mortality over four decades. BMI strengthened its association with time, while cigarette smoking was strongest in all periods.