International trends in coronary heart disease mortality and incidence rates

Whole Milk and Full-Fat Dairy Products and Hypertensive Risks

Lifestyle modifications in the form of diet and exercise are generally a first-line approach to reduce hypertensive risk and overall cardiovascular disease (CVD) risk. Accumulating research evidence has revealed that consumption of non- and low-fat dairy products incorporated into the routine diet is an effective means to reduce elevated blood pressure and improve vascular functions. However, the idea of incorporating whole-fat or full-fat dairy products in the normal routine diet as a strategy to reduce CVD risk has been met with controversy. The aim of this review is to review both sides of the argument surrounding saturated fat intake and CVD risk from the standpoint of dairy intake. Throughout the review, we examined observational studies on relationships between CVD risk and dairy consumption, dietary intervention studies using non-fat and whole-fat dairy, and mechanistic studies investigating physiological mechanisms of saturated fat intake that may help to explain increases in cardiovascular disease risk. Currently available data have demonstrated that whole-fat dairy is unlikely to augment hypertensive risk when added to the normal routine diet but may negatively impact CVD risk. In conclusion, whole-fat dairy may not be a recommended alternative to non- or low-fat dairy products as a means to reduce hypertensive or overall CVD risk.

Association of Depression with Subclinical Coronary Atherosclerosis: a Systematic Review

To assess causal association of depression with subclinical coronary atherosclerosis, we performed computer-based and manual search of literature for studies which had assessed relationship of depression disorder with coronary atherosclerosis. All studies had diagnosed depression with validated tools in patients without diagnosed coronary artery disease. The Bradford Hill criteria of cause-effect association was consistently fulfilled by those studies which achieved statistical significance and further showed incremental strength of association with one or more of the following attributes: (1) prospective cohort study, met cause-effect criteria of "temporality"; (2) relatively severe and/or longer period of depression, met cause-effect criteria of "dose-response"; (3) depression with predominantly somatic symptoms cluster, met cause-effect criteria of "scientific plausibility"; (4) multiethnic larger sample, met cause-effect criteria of "population equivalence"; and (5) multicenter study, met criteria of "environmental equivalence." Our results show that there is a significant association of depression with coronary atherosclerosis at its subclinical stages.

Association between beta-adrenoceptor antagonist-induced sympathicolysis and severity of coronary artery disease as assessed by coronary computed tomography angiography (CCTA)

Enhanced sympathetic nervous system activity is associated with increased mortality in many cardiac conditions including heart failure and coronary artery disease (CAD). To ensure adequate image quality of coronary CT angiography (CCTA), pre-scan β-adrenergic blockers (BB) are routinely administered. It is currently unknown whether sensitivity to sympathicolytic compounds is associated with severity of CAD. A total of 2633 consecutive patients (1733 [65.8%] men and 900 [34.2%] women, mean age 56.7 ± 11.5 years) undergoing CCTA for exclusion of significant CAD at our department between 06/2013 and 12/2016 were evaluated. Acute heart rate (HR) responses to BB administration were recorded in all patients. Coronary plaque burden as indicated by segment severity score (SSS), segment involvement score (SIS), and significant CAD (i.e. > 50% luminal narrowing) was higher in weak responders to BB as compared to strong responders to BB (p = 0.001 for SSS and SIS, and p = 0.021 for significant CAD). Accordingly, in a multiple linear regression model adjusted for known risk factors of CAD such as smoking, hypertension, diabetes and dyslipidaemia, as well as age, sex, body mass index (BMI), glomerular filtration rate, and HR during CCTA scan, a strong response to BB was selected as a significant independent negative predictor of coronary plaque burden (beta coefficient - 0.08, p = 0.001). We demonstrate that individuals with a weak acute response to BB administration encounter an increased risk of severe CAD. Taking into account sensitivity to sympatho-inhibition may add complementary information in patients undergoing CCTA for evaluation of CAD.

Estimating the incidence of the acute coronary syndrome: data from a Danish cohort of 138290 persons

Background

Estimates of incidence are crucial to the planning of public health measures, but most studies of incidence of, for example, acute myocardial infarction (MI) are troubled by methodological problems such as; (i) selection biases of the patients being included for study, (ii) lack of identification and control of the cohort under observation, (iii) inconsistencies in the use of diagnostic criteria, and (iv) missing data. We aimed to measure directly the incidence of the entire spectrum of the acute coronary syndrome (ACS), consisting of unstable angina pectoris, MI and sudden cardiac death (SCD), by use of the new criteria for MI as proposed in 2000. Design Cohort study.

Methods

From a cohort of 138 290 residents of the municipality of Aarhus, Denmark, aged 30-69 years, with a demographic structure known at the individual population member level, we prospectively identified all consecutive ACS patients from 1 April 2000 to 31 March 2002. The population was identified from Danish Population Registers.

Results

A total of 189 victims of SCD and 457 ACS patients who survived until admission to hospital were present. Consequently, crude incidence rate of ACS was 234 per 100000 person-years. Unstable angina pectoris constituted for 16.9%, MI for 53.8% and SCD for 29.3% of ACS patients.

Conclusions

Crude incidence rates of ACS were 137 and 331 per 100 000 person years for women and men, respectively. The incidence rate of ACS, as measured directly, was insignificantly 6% higher than expected from Danish administrative databases. Eur J Cardiovasc Prev Rehabil 14:608-614 © 2007 The European Society of Cardiology

Is the incidence of heart attack still decreasing in Australia? Developing reliable methods for monitoring trends in myocardial infarction and coronary heart disease (AUS-MOCHA): a study protocol

INTRODUCTION

Accurate monitoring of acute coronary heart disease (CHD) is essential for understanding the effects of primary and secondary prevention and for planning of healthcare services. The ability to reliably monitor acute CHD has been affected by new diagnostic tests for myocardial infarction (MI) and changing clinical classifications and management of CHD. Our study will develop new and reliable methods for monitoring population trends in incidence, outcomes and health service usage for acute CHD and chest pain.

METHODS AND ANALYSIS

The study cohort of all CHD will be identified from the Western Australian Data Linkage System using state-wide data sets for emergency department presentation, hospitalisations and mortality data for 2002-2014. This core linked data set will be supplemented with data from hospital medical record reviews, pathology data and hospital pharmacy dispensing databases. The consistency over time of the coding of the different subgroups of CHD/chest pain (ST-elevation MI, non-ST elevation MI, unstable angina, stable angina, other CHD, non-CHD chest pain) in linked data will be assessed using these data sources, and an algorithm developed detailing groups in which temporal trends can be reliably measured. This algorithm will be used for measurement of trends in incidence and outcomes of acute CHD, and to develop further methods for monitoring acute CHD using unlinked and linked data with varying availability of hospitalisation history.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Human Research Ethics Committees of the WA Department of Health (#2016/23) and The University of Western Australia (RA/4/1/7230). Findings will be disseminated via publication in peer-reviewed journals, and presentation at national and international conferences. There will also be a strong platform for dissemination of new monitoring methods via collaboration with the Australian Institute of Health and Welfare which will assist with promotion of these methods at state and national levels.

Geographical variation in a fatal outcome of acute myocardial infarction and association with contact to a general practitioner

BACKGROUND

Geographical variation in incidence and mortality of acute myocardial infarction (AMI) is present in Denmark. We aimed at examining the association between contact to a general practitioner (GP) the year before AMI and a fatal outcome of AMI.

METHODS

Register-based data and individual-level addresses including 69,608 individuals with AMI in 2006-2011. A Bayesian hierarchical logistic regression model was used to examine the association.

RESULTS

A fatal outcome of AMI was seen among 12.0% (78%) of individuals with (without) contact to a GP the year before AMI. A significant association was estimated.

CONCLUSIONS

A fatal outcome of AMI was significantly associated with contact to a GP. A high population to GP ratio and long distance to GP could not explain the increased odds of a fatal outcome of AMI for individuals with no contact to a GP.

The Effect of the Mediterranean Diet on Hypertension: A Systematic Review and Meta-Analysis

OBJECTIVE

The adoption of a Mediterranean diet (MD) pattern of eating is often described as a strategy to help prevent or manage hypertension. However, this dietary regimen has not been reviewed systematically for its efficacy against hypertension. Therefore, the purpose of this study was to analyze the effect of interventions of at least 1 year duration on blood pressure (BP) values through a systematic review and meta-analysis. The focus was on interventions comparing an MD with a low-fat diet.

DESIGN

The authors accessed and searched PubMed and Scopus databases up to March, 2015. Randomized control trials comparing MD vs low-fat diet were included. The researchers assessed the methodological quality, extracted the valid data, and conducted the meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Six trials (more than 7,000 individuals) were identified. Meta-analysis showed that interventions aiming at adopting an MD pattern for at least 1 year reduced both the systolic BP and diastolic BP levels in individuals with normal BP or mild hypertension. The effect was higher for the systolic BP (-1.44 mm Hg) but also consistent for the diastolic BP (-0.70 mm Hg). However, the results have to be interpreted with caution owing to the reduced number of studies eligible for inclusion in this meta-analysis. This situation limited the statistical power of the analyses. Furthermore, in all analyses, the pooled effect estimation showed a high evidence of heterogeneity, which compromises the validity of the pooled estimates.

CONCLUSIONS AND IMPLICATIONS

A positive and significant association was found between the MD and BP in adults. However, in all cases the magnitude of the effect was small. Based on this limited group of studies and their heterogeneity, the authors found insufficient convincing evidence to suggest that the MD decreased BP. Further standardized research is urgently needed to reach evidence-based conclusions to clarify the role of MD in BP management, particularly in Europe and other societies where prevalence of cardiovascular diseases is increasing.

Serum palmitic acid-oleic acid ratio and the risk of coronary artery disease: a case-control study

Serum free fatty acids are risk factors for future coronary artery disease (CAD). We investigated the association between serum palmitic acid (PA)-oleic acid (OA) ratio and CAD risk in a case-control (n=108/129) study. The PA-OA ratio was associated with future CAD events independently of standard lipid values. The PA-OA ratio was significantly associated with the risk of fatal CAD [odds ratio (OR): 60.4; 95% confidence interval (CI): 11.5-316.9; P<.001] while inversely associated in nonfatal CAD group (OR: 0.11; 95% CI: 0.02-0.53; P<.01), and no distinct modification by sex was found. Receiver-operating characteristic (ROC) analysis found that PA-OA ratio did as well as triglyceride (TG) and apolipoprotein B (apo B)-high-density lipoprotein cholesterol (HDLC) ratio at discriminating fatal CAD (area under ROC, TG, 0.692; apo B-HDLC, 0.683; PA-OA, 0.768, P<.001), and had similar effect with HDLC at discriminating nonfatal CADs (area under ROC, HDLC, 0.649; PA-OA, 0.659, P<.01).These findings suggested that PA-OA ratio did as well as and even better than traditional risk factors and arteriography examination in discriminating fatal and nonfatal CAD events. Serum PA-OA ratio could be a new factor for CAD risk assessment and prediction.

Dietary intake of total marine n-3 polyunsaturated fatty acids, eicosapentaenoic acid, docosahexaenoic acid and docosapentaenoic acid and the risk of acute coronary syndrome – a cohort study

Dietary intake of marine n-3 PUFA has been negatively associated with the risk of CHD among subjects with known CHD, whereas an effect in healthy subjects is less documented. We assessed the hypothesis that dietary intake of marine n-3 PUFA is negatively associated with the risk of acute coronary syndrome (ACS) in healthy subjects. In the Danish Diet, Cancer and Health cohort study, 57 053 participants were enrolled. Dietary intake of total n-3 PUFA, including EPA, docosapentaenoic acid (DPA) and DHA, was assessed. During a mean follow-up period of 7·6 years, we identified all cases (n 1150) from this cohort with an incident ACS diagnosis in the Danish National Patient Registry or the Cause of Death Registry. Diagnoses were verified through medical record review. In Cox proportional hazard models, we adjusted for established risk factors for CHD. Men in the four highest quintiles of n-3 PUFA intake (>0·39 g n-3 PUFA per d) had a lower incidence of ACS compared with men in the lowest quintile. The hazard ratio was 0·83 (95 % CI 0·67, 1·03) when we compared men in the second lowest and lowest quintile of n-3 PUFA intake. Higher intake of n-3 PUFA did not strengthen this association. Associations for EPA, DPA and DHA were all negative, but less consistent. No convincing associations were found among women. In conclusion, we found borderline significant negative associations between the intake of marine n-3 PUFA and ACS among healthy men.

Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review

This systematic review of population-based studies of the incidence and early (21 days to 1 month) case fatality of stroke is based on studies published from 1970 to 2008. Stroke incidence (incident strokes only) and case fatality from 21 days to 1 month post-stroke were analysed by four decades of study, two country income groups (high-income countries and low to middle income countries, in accordance with the World Bank's country classification) and, when possible, by stroke pathological type: ischaemic stroke, primary intracerebral haemorrhage, and subarachnoid haemorrhage. This Review shows a divergent, statistically significant trend in stroke incidence rates over the past four decades, with a 42% decrease in stroke incidence in high-income countries and a greater than 100% increase in stroke incidence in low to middle income countries. In 2000-08, the overall stroke incidence rates in low to middle income countries have, for the first time, exceeded the level of stroke incidence seen in high-income countries, by 20%. The time to decide whether or not stroke is an issue that should be on the governmental agenda in low to middle income countries has now passed. Now is the time for action.

Predictive values of acute coronary syndrome discharge diagnoses differed in the Danish National Patient Registry

OBJECTIVE

To investigate the predictive value of acute coronary syndrome (ACS) diagnoses, including unstable angina pectoris, myocardial infarction, and cardiac arrest, in the Danish National Patient Registry.

STUDY DESIGN AND SETTING

We identified all first-time ACS diagnoses in the Danish National Patient Registry among participants in the Danish cohort study "Diet, Cancer and Health" through the end of 2003. We retrieved and reviewed medical records based on current European Society of Cardiology criteria for ACS.

RESULTS

We reviewed hospital medical records of 1,577 out of 1,654 patients (95.3%) who had been hospitalized with a first-time ACS diagnosis. The overall positive predictive value for ACS was 65.5% (95% confidence interval [CI]=63.1-67.9%). Stratification by sub-diagnosis and hospital department produced significantly higher positive predictive values for myocardial infarction diagnoses (81.9%; 95% CI=79.5-84.2%) and among patients who received an ACS diagnosis in a ward (80.1%; 95% CI=77.7-82.3%).

CONCLUSION

The ACS diagnoses contained in hospital discharge registries should be used with caution. If validation is not possible, restricting analyses to patients with myocardial infarction and/or patients discharged from wards might be a useful alternative.

Cardioprotection in female rats subjected to chronic volume overload: synergistic interaction of estrogen and phytoestrogens

Intact female rats fed a high-phytoestrogen diet are protected against adverse left ventricular (LV) remodeling induced by chronic volume overload. We hypothesized that both phytoestrogens and ovarian hormones, particularly estrogen, are necessary for this dietary-induced cardioprotection. To test this hypothesis, eight groups of female rats were studied; rats were fed either a high-phytoestrogen (+phyto) or phytoestrogen-free diet. Groups included sham-operated rats, intact rats with fistula (Fist), ovariectomized rats with fistula (Fist-OX), and Fist-OX rats treated with estrogen (EST). Myocardial function and remodeling were assessed after 8 wk of volume overload using a blood-perfused isolated heart apparatus. Fist-OX rats developed significant ventricular dilatation and increased compliance vs. intact Fist rats, which were associated with a significant decrease in contractility. Estrogen treatment prevented pulmonary edema and attenuated LV hypertrophy and dilatation but did not maintain contractility. However, dietary phytoestrogens completely prevented LV dilatation in both the Fist+phyto and Fist-OX+EST+phyto groups but had no effect on LV remodeling in the Fist-OX+phyto group. Contractility was significantly greater in the estrogen-treated rats fed the phytoestrogen diet than in those treated with estrogen alone. Dietary phytoestrogens did not affect LV or uterine mass, serum estrogen, LV estrogen receptor expression, or cardiac function in sham animals. These data indicate that estrogen is not solely responsible for the cardioprotection exhibited by intact females and that phytoestrogens can work synergistically with ovarian hormones to attenuate ventricular remodeling induced by chronic volume overload in female rats.

Danish singles have a twofold risk of acute coronary syndrome: data from a cohort of 138 290 persons

STUDY OBJECTIVE

Atherosclerosis of the coronary and other arteries is an important health problem in virtually all countries of the world, and thus there is a persisting need for the development of preventive programmes including population risk group identification. The aim of the study was to identify sociodemographic population risk indicators of an initial episode of acute coronary syndrome (ACS), including unstable angina pectoris (UAP), myocardial infarction (MI), and sudden cardiac death (SCD).

DESIGN

Cohort study of 138 290 residents of the municipality of Aarhus, Denmark, aged 30-69 years. Information on population members' individual age, sex, social background, and eventual death was obtained from Danish Population Registers.

SETTING

University hospital.

PATIENTS

The study prospectively identified 646 victims of ACS from 1 April 2000 to 31 March 2002.

MAIN RESULTS

Based on multiple logistic regression, age and single living were found to be positively associated with incident ACS in both sexes. Women >60 years living alone and men >50 years living alone were at especially high risk. They constituted only 5.4% and 7.7% of the source population, respectively, but they accounted for 34.3% and 62.4% of ACS patients dying within 30 days.

CONCLUSIONS

Single living is associated with an increased risk of ACS. Thus, risk groups identified by use of information on their age and family structure may be targets for future more focused and cost effective preventive strategies. In Western populations, such high risk groups will constitute comparatively limited parts of the population, and in Denmark they are easily identifiable in routine population registers.

An indium:calcium phosphate colloid that specifically targets fibrin

The ability of indium to target fibrin in vitro was evaluated. The radionuclide (114m)Indium (114mIn) was prepared as a soluble and colloidal (In:In) form, as well as, a mixed indium:calcium phosphate (In:CaP) colloid. Soluble 114mIn was prepared by maintaining acid pH (50 mM HCl). Colloidal 114mIn (In:In) was prepared under slightly basic conditions (50 mM Tris-Cl, pH 7.6). The mixed In:CaP colloid was prepared by incubation of 114mIn with calcium (10 mM) and phosphate (250 microM) under slightly basic conditions (50 mM Tris-Cl, pH 7.6). To assess fibrin binding, the three 114mIn preparations were mixed with diluted human plasma (source of fibrinogen). Fibrin polymerization was initiated by addition of calcium (5 mM) and thrombin (0.5 U/ml). Following incubation (15 min, 37 degrees C), the fibrin matrix was condensed, removed from the reaction mixture, and washed briefly. Fibrin uptake of 114mIn (soluble, colloidal, or In:CaP) was determined by gamma counting. Results demonstrated that soluble 114mIn exclusively bound a plasma protein electrophoretically and immunologically identified as transferrin. Although both colloidal 114mIn and 114mIn:CaP bound fibrin, the mixed 114mIn:CaP colloid demonstrated substantially higher fibrin binding activity (about 2-fold). The target of indium binding was confirmed as fibrin due to the presence of characteristic cross-linked gamma-gamma dimers (100 kDa) and beta-monomers (58 kDa) by SDS-PAGE. 114mIn colloid and the mixed 114mIn:CaP colloid demonstrated no ability to bind fibrin's precursor, fibrinogen. 114mIn:CaP fibrin binding was associated with formation of CaP, as evidenced by its dependence on phosphate concentration. The biocompatibility of CaP including its ability to bind 114mIn and specifically target fibrin may be of potential value for diagnostic imaging studies to identify regions of occult vascular stenosis (i.e., atherosclerotic plaques, deep vein thrombosis, pulmonary embolus).

Changes in hospitalization rate and mortality after acute myocardial infarction in Denmark after diagnostic criteria and methods changed

AIMS

To analyse the effect of the change in diagnostic criteria for acute myocardial infarction (AMI) and the use of troponin as a diagnostic marker on the hospitalization rate and mortality of hospitalized AMI patients from 1994 to 2001.

METHODS AND RESULTS

Patients (> or =30 years) admitted for their first AMI were identified using the National Patient Registry in Denmark. We registered when each hospital introduced troponin as a diagnostic marker. The reported hospitalization rate decreased until 1998 and then increased substantially from 1999 to 2001 from 3472 to 4163 per million inhabitants (19.9%) for men and from 1648 to 2020 per million inhabitants (22.6%) for women. Troponin use was associated with a significant 14% increase in hospitalization rate in this period [rate ratio 1.14, 95% confidence interval (CI) 1.11-1.18]. The effect of troponin was greatest among patients 70 years and older (rate ratio 1.19, 95% CI 1.14-1.23). The 28 day mortality decreased steadily from 25.9% in 1994 to 17.5% in 2002 (32.4%) and was not affected by troponin use.

CONCLUSION

The reported hospitalization rate for AMI increased significantly after the new diagnostic criteria for AMI were introduced. The measurement of cardiac troponins further increased the hospitalization rate. The mortality among hospitalized patients with AMI declined steadily and was not affected by the use of troponins.

Estrogenicity of the Isoflavone Metabolite Equol on Reproductive and Non-Reproductive Organs in Mice1

Equol, a metabolite of the phytoestrogen daidzein, is present at significant levels in some humans who consume soy and in rodents fed soy-based diets. Equol is estrogenic in vitro, but there have been limited studies of its activity in vivo. We evaluated equol effects on reproductive and non-reproductive endpoints in mice. Ovariectomized age-matched (30-day-old) female C57BL/6 mice were fed phytoestrogen-free diets and given a racemic mixture of equol by daily injections (0, 4, 8, 12, or 20 mg [kg body weight](-1) day(-1)) or in the diet (0, 500, or 1,000 ppm) for 12 days. Mice were killed, and serum concentrations of total and aglycone equol were measured. Total serum equol concentrations ranged from 1.4 to 7.5 microM with increasing doses of injected equol, but uterine weight increased significantly only at 12 and 20 mg (kg body weight)(-1) day(-1). Dietary equol at 500 or 1,000 ppm produced total serum equol concentrations of 5.9 and 8.1 microM, respectively, comparable with those in rodents consuming certain high-soy chows; the proportion of equol present as the free aglycone was much lower with dietary administration than injections, which may be a factor in the greater biological effects induced by injections. Dietary equol did not significantly increase uterine weight. Increasing dietary and injected equol doses caused a dose-dependent increase in vaginal epithelial thickness. Uterine epithelial proliferation was increased by equol injections at 8-20 mg (kg body weight)(-1) day(-1) and 1,000 ppm dietary equol. Neither dietary nor injected equol decreased thymic or adipose weights. In conclusion, equol is a weak estrogen with modest effects on endpoints regulated by estrogen receptor alpha when present at serum levels seen in rodents fed soy-based diets, but quantities present in humans may not be sufficient to induce estrogenic effects, although additive effects of equol with other phytoestrogens may occur.

Coronary artery disease in the developing world

BACKGROUND

Coronary artery disease (CAD) is the leading cause of cardiovascular mortality worldwide, with >4.5 million deaths occurring in the developing world. Despite a recent decline in developed countries, both CAD mortality and the prevalence of CAD risk factors continue to rise rapidly in developing countries. The objectives of the current article are to review (1) the literature regarding CAD mortality and the prevalence of CAD risk factors in the developing world, and (2) prevention and control measures.

METHODS

We conducted a MEDLINE search of the English language literature for the years 1990 to 2002 to identify articles pertaining to the prevalence of CAD in developing countries. The search was performed using the following key terms: coronary artery disease, developing countries, ischemic heart disease, incidence, prevalence, prevention and risk factors. We also obtained relevant statistical information from The World Health Organization's Internet database.

RESULTS

There is a paucity of data regarding CAD and its prevalence in the developing world. However, it is projected that CAD mortality rates will double from 1990 to 2020, with approximately 82% of the increase attributable to the developing world. Existing data suggest that rapid socioeconomic growth in developing countries is increasing exposure to risk factors for CAD, such as diabetes, genetic factors, hypercholesterolemia, hypertension, and smoking. There is a relative lack of prevention and control measures to decrease exposure to these risk factors in developing countries.

CONCLUSION

Documented information on the prevalence of CAD in developing countries is sparse, but there is sufficient data to suggest an impending epidemic. Prevention and targeted control of risk factors for CAD could potentially reduce the impact of CAD in the developing world as it has in industrialized nations.

Is income inequality a determinant of population health? Part 2. U.S. National and regional trends in income inequality and age- and cause-specific mortality

This article describes U.S. income inequality and 100-year national and 30-year regional trends in age- and cause-specific mortality. There is little congruence between national trends in income inequality and age- or cause-specific mortality except perhaps for suicide and homicide. The variable trends in some causes of mortality may be associated regionally with income inequality. However, between 1978 and 2000 those regions experiencing the largest increases in income inequality had the largest declines in mortality (r= 0.81, p < 0.001). Understanding the social determinants of population health requires appreciating how broad indicators of social and economic conditions are related, at different times and places, to the levels and social distribution of major risk factors for particular health outcomes.

The search for new risk factors for coronary heart disease: occupational therapy for epidemiologists?

The identification of the proximal causes of coronary heart disease (CHD) during the second half of the 20th century contributed to the prevention of premature CHD and the extension of life expectancy in middle-aged and older people in many wealthy countries. These major CHD risk factors-high blood cholesterol, high blood pressure, cigarette smoking and physical inactivity-satisfy public health criteria of causality. Strong epidemiological evidence suggests that they explain at least 75% of new cases of CHD. However, the search for 'new' or 'emerging' CHD risk factors continues, partly justified by a myth that minimizes the contribution of the major risk factors. The public health criteria of causality were applied to the following proposed new risk factors: thrombotic factors and serum homocysteine levels; infectious agents; early life exposures including prenatal factors; genetic influences; oestrogen deficiency; and the role of the psychosocial environment. None of these factors are as important as the established risk factors for epidemic CHD and their potential contribution for improving population health is limited or unclear. Research into unexplained variations in the occurrence of CHD and into life course influences and socioeconomic inequalities may provide extra leads to effective public health action. Especially important is research on the upstream social and economic determinants of CHD and its major risk factors, on the spread of the CHD epidemic to poorer populations, and into prevention policy and programme effectiveness. Available evidence supports the feasibility and effectiveness of population-wide prevention directed towards increasing the proportion of people at low risk of CHD. The vast majority of the public health effort should be directed to this approach rather than to the high risk individual approach. There is still a major gap between knowledge and action in preventing the CHD epidemics.

Phytoestrogen concentrations in serum from Japanese men and women over forty years of age

Asian individuals have much lower incidences of prostate and breast cancer than populations from Western developed countries. They also consume a lower fat, higher fiber diet, with a large intake of phytoestrogens. These phytoestrogens may protect against hormone-dependent cancers and other diseases. Our study used established gas chromatography-mass spectrometry (GC-MS) methodologies to measure the concentrations of four phytoestrogens (daidzein, genistein, equol and enterolactone) in serum samples obtained from Japanese men (n = 102) and women (n = 125) > 40 y old. The results were compared with those obtained with samples from the UK. The Japanese men and women had higher (P < 0.001) concentrations of circulating daidzein, genistein and equol than individuals from the UK. The mean concentration of genistein in Japanese men, for example, was 492.7 nmol/L, compared with 33.2 nmol/L in men from the UK. The two populations, however, had similar serum concentrations of enterolactone. Furthermore, 58% of the Japanese men and 38% of the Japanese women had equol concentrations > 20 nmol/L, compared with none of the UK men and 2.2% of the UK women. These results support previously published GC-MS results from studies with low numbers of samples.

Chemopreventive effects of cocoa polyphenols on chronic diseases

We have explored the causes of the major chronic diseases prevailing in the world and the relevant mechanisms as a sound basis for recommendations for their prevention. Research shows that the cocoa bean, and tasty products derived from the cocoa bean such as chocolate, and the beverage cocoa, popular with many people worldwide, is rich in specific antioxidants, with the basic structure of catechins and epicatechin, and especially the polymers procyanidins, polyphenols similar to those found in vegetables and tea. Metabolic epidemiological studies indicate that regular intake of such products increases the plasma level of antioxidants, a desirable attribute as a defense against reactive oxygen species (ROS). The antioxidants in cocoa can prevent the oxidation of LDL-cholesterol, related to the mechanism of protection in heart disease. Likewise, a few studies show that ROS associated with the carcinogenic processes is also inhibited, although there have not been many studies on a possible lower risk of various types of cancer either in humans or in animal models consuming cocoa butter or chocolates. Based on the knowledge acquired thus far, it would seem reasonable to suggest inhibition of the several phases of the complex processes leading to cancer, as a function of quantitative intake of antioxidants, including those from cocoa and chocolates. Cocoa and chocolate also contain fats from cocoa butter. These are mainly stearic triglycerides (C18:0) that are less well absorbed than other fats, and are excreted in the feces. Thus, cocoa butter is less bioavailable and has minimal effect on serum cholesterol.

The CardioVision 2020 baseline community report card

OBJECTIVE

To establish baseline data for the CardioVision 2020 program, a collaborative project in Olmsted County, Minnesota, organized to reduce cardiovascular disease rates by altering 5 health-related items: (1) eliminating tobacco use and exposure, (2) improving nutrition, (3) increasing physical activity, (4) lowering serum cholesterol level, and (5) controlling blood pressure.

SUBJECTS AND METHODS

Data about tobacco use, diet, and physical activity were collected by random digit dial interview and follow-up questionnaire from a sample of the population. Blood pressure data were collected from medical records at Mayo Clinic, and serum cholesterol data were derived from the Mayo Clinic laboratory database. Data were stratified into 6 age groups.

RESULTS

A total of 624 women and 608 men responded to the questionnaire. Population blood pressure data were available for 1,956 women and 1,084 men. Population serum cholesterol data were available for 17,042 women and 12,511 men. Except for women in the 30- to 39-year-old age group, less than 10% of the population sampled met 4 or 5 goals. Conversely, about 90% of the population met at least 1 goal, and about 80% met 1, 2, or 3 of the goals.

CONCLUSION

The data from the Olmsted County population indicate considerable opportunity to reduce this population's burden of cardiovascular disease.

Eat to live, not live to eat

Most of the prevailing chronic diseases in the world have an important nutritional component by directly causing a specific disease, enhancing the risk through phenomena of promotion, exerting a beneficial effect in decreasing risk, or preventing the disease. International studies in geographic pathology have shown that a given disease may have vastly different incidence and mortality as a function of residence. Laboratory research in animal models can reproduce fairly accurately what is learned through international research and provide the basis for examining relevant hypotheses and, more importantly, proposed mechanisms of action. Validation of these approaches can be the basis for public-health recommendations and health-promotion activities. Through such techniques, it has been found that regular intake of foods with saturated fats such as meat and certain dairy products raise the risk of coronary heart disease. The total mixed-fat intake is associated with a higher incidence of the nutritionally linked cancers, specifically cancer of the postmenopausal breast, distal colon, prostate, pancreas. ovary, and endometrium. The associated genotoxic carcinogens for several of these cancers are heterocyclic amines, which also play a role in heart-disease causation, and these are produced during the broiling and frying of creatinine-containing foods such as meats. Monounsaturated oils such as olive or canola oil are low-risk fats as shown in animal models and through the observation that the incidence of specific diseases is lower in the Mediterranean region, where such oils are customarily used. High salt intake is associated with high blood pressure and with stomach cancer, especially with inadequate intake of potassium from fruits and vegetables and of calcium from certain vegetables and low-fat dairy products. Vegetables, fruits, and soy products are rich in antioxidants that are essential to lower disease risk stemming from reactive oxygen systems in the body. Green and black teas are excellent sources of antioxidants of a polyphenol nature. as is cocoa and some chocolates. Nutritional lifestyles that offer the possibility of a healthy long life can be adopted by most populations in the world.