Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Metabolic syndrome and heart failure: 40 years follow up results of the Seven Countries Study

Introduction

Metabolic syndrome (Met Sy) as a highly debatable cluster of traditional risk factors is known to promote cardiometabolic-related morbidity and mortality, but its precise mechanisms remain to be determined.

Purpose

We sought to determine influence of MetSy on heart failure (HF) morbidity and mortality in the Seven Countries' Study as one of the oldest epidemiological studies.

Methods

The Seven Countries Study encompassed 12,763 participants from 3 continents who were all healthy men of over 40 years at baseline and who underwent regular check ups every 5 years throughout over a 4 decades' span. Morbidity and mortality was adjudicated according to valid ICD and LPH coding.

Results

Using the IDF definition of the Metabolic Syndrome, 9,09% of participants were identified (Figure 1). HF was confirmed in 220 patients (16.4% alive at 40y follow up visit), while 8.2% died of HF as well in the same time-frame (Tables 1 & 2). Presence of MetSy has been shown to significantly influence HF mortality (Figures 2) with lowest survival of 22% for 300 months of follow up for patients with both MetSy and HF (Log rank test=4.405, p<0.0001).

Conclusion

Metabolic syndrome treatment remains in the realm of risk factors' control that now we know influence both ischemic heart disease and heart failure of other origins. Historically, just emerging biomarkers' and targeted imaging weren't available to determine such at the time of HF diagnosis. Also, the sample consisted of men only, mainly Caucasian and a modest proportion of Asian and African-American now known to carry ethnic-specific burden of cardiovascular disease. All of the above, emphasizes the importance of more diversity, equity and inclusion-dedicated long term both observational, as well as interventional research.

Funding Acknowledgement

Type of funding sources: None.

Metabolic syndrome and mortality prediction in the seven countries' study: single or multifactorial

Introduction

The metabolic syndrome (Met Sy) is a known cluster of risk factors (HTA, HLP, DM, BMI) that promotes overall vascular disease, however its real impact on overall, ischemic heart disease (IHD) and cerebrovascular disease (CVD) mortality remains debated.

Material and methods

The Seven Countries Study encompassed 12,763 participants who were healthy men over 40y at baseline and who underwent regular check ups every 5 years throughout over a 4 decades' span. Morbidity and mortality was adjudicated according to valid ICD and LPH coding.

Results

Using the IDF definition of the Metabolic Syndrome, 9,09% of participants were identified. In a multivariate analysis predictors for overall Mt were hypertension (p<0.0001) and BMI (p<0.029), while HLP had a weak prediction value (p=0.083), where as MetSy and DM had not at all. Hypertension (p<0.0001) remained a strong predictor for IHD mortality together with HLP (p<0.0001), while diabetes was of weak predictive value (p=0.065), whereas MetSy failed to. Although HTA was a strong predictor for CVD mortality, so did MetSy (p<0.050), while DM and HLP haven't while BMI had a low impact (p=0.070).

Conclusion

Metabolic syndrome's role in atherosclerotic burden remains important, however whether its power is due to its respective components or their interactions remains to be an issue. The described results belong to an era where both IHD and CVD were considered a “male disease” women were spared of, so, further validation in the described cohorts is needed in an offspring fashion, however hypertension remains the driving force of both overall mortality as well as specific IHD and CVD ones, also previously demonstrated in the very same cohort to be more important in the setting of maternal family history of hypertension, than paternal one.

MetSy in the SCS

Funding Acknowledgement

Type of funding source: None

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

The 2015 Dutch food-based dietary guidelines

The objective of this study was to derive food-based dietary guidelines for the Dutch population. The dietary guidelines are based on 29 systematic reviews of English language meta-analyses in PubMed summarizing randomized controlled trials and prospective cohort studies on nutrients, foods and food patterns and the risk of 10 major chronic diseases: coronary heart disease, stroke, heart failure, diabetes, breast cancer, colorectal cancer, lung cancer, chronic obstructive pulmonary disease, dementia and depression. The committee also selected three causal risk factors for cardiovascular diseases or diabetes: systolic blood pressure, low-density lipoprotein cholesterol and body weight. Findings were categorized as strong or weak evidence, inconsistent effects, too little evidence or effect unlikely for experimental and observational data separately. Next, the committee selected only findings with a strong level of evidence for deriving the guidelines. Convincing evidence was based on strong evidence from the experimental data either or not in combination with strong evidence from prospective cohort studies. Plausible evidence was based on strong evidence from prospective cohort studies only. A general guideline to eat a more plant food-based dietary pattern and limit consumption of animal-based food and 15 specific guidelines have been formulated. There are 10 new guidelines on legumes, nuts, meat, dairy produce, cereal products, fats and oils, tea, coffee and sugar-containing beverages. Three guidelines on vegetables, fruits, fish and alcoholic beverages have been sharpened, and the 2006 guideline on salt stayed the same. A separate guideline has been formulated on nutrient supplements. Completely food-based dietary guidelines can be derived in a systematic and transparent way.

Healthy eating and survival among elderly men with and without cardiovascular-metabolic diseases

BACKGROUND AND AIMS

The strength of the associations of dietary scores with cardiovascular disease (CVD) and all-cause mortality in elderly vary considerably between a priori scores. To assess whether healthy eating lowers the risk of CVD and all-cause mortality among elderly men.

METHODS AND RESULTS

The Zutphen Elderly Study (age 65-84 years) was divided into men with (n = 210) and without (n = 616) cardiovascular-metabolic diseases at baseline in 1985. Diet was assessed with the cross-check dietary history method. We created the "Dutch Healthy Nutrient and Food Score" (DHNaFS) and the "Dutch Undesirable Nutrient and Food Score" (DUNaFS). Associations of the scores with CVD and all-cause mortality were assessed using multivariable Cox regression models. Associations of scores with life years gained used general linear models. During a median follow-up of 10.6 years (IQR 5.8-15.9) 806 participants died, of whom 359 from CVD. In all men, diet scores did not predict death. Among men with cardiovascular-metabolic diseases, DHNaFS was associated with lower CVD (HR: 0.57; 95% CI: 0.35-0.93) and all-cause mortality risk (HR: 0.64; 95% CI: 0.44-0.94) comparing the highest vs. the lowest score tertiles. Men with cardiovascular-metabolic diseases in the highest vs. the lowest tertile of the DHNaFS lived approximately 2.5 years longer. The DHNaFS was not associated with CVD and all-cause mortality in men without cardiovascular-metabolic diseases. The DUNaFS was not associated with any of the outcomes.

CONCLUSION

A high quality diet was associated with a 40% lower mortality risk and 2.5 years longer life expectancy in elderly men with, but not without, cardiovascular-metabolic diseases.

Fish and omega-3 fatty acid intake in relation to circulating fibroblast growth factor 23 levels in renal transplant recipients

BACKGROUND AND AIMS

A high circulating fibroblast growth factor 23 (FGF23) level is an independent risk factor for cardiovascular mortality in renal transplant recipients and the general population. N-3 fatty acids eicosapentaenoic (EPA) and docosahexaenoic acid (DHA) may contribute to cardiovascular risk reduction. We investigated whether fish and EPA-DHA intake are related to FGF23 levels in renal transplant recipients.

METHODS AND RESULTS

We performed a cross-sectional analysis in 619 stable renal transplant recipients (mean age 53 years, 57% male, estimated glomerular filtration rate [eGFR] 53 ± 20 mL/min/1.73 m(2)). Dietary intake was assessed by a 177-item food frequency questionnaire. Serum intact FGF23 was measured by ELISA. We examined differences in FGF23 levels across categories of fish and EPA-DHA intake using analysis of variance models adjusted for age, sex, dietary and lifestyle factors and key determinants of FGF23. Patients consumed on average 15 g of fish and 139 mg EPA-DHA/day. Median FGF23 was 62 pg/mL (IQR 43-98 pg/mL). Higher dietary EPA-DHA and fish intake were associated with lower serum FGF23 levels. Subgroup analyses revealed that particularly in patients with reduced renal function (eGFR <60 mL/min/1.73 m(2)), adjusted FGF23 levels (114, 79, 75 pg/mL, P = 0.0001) were inversely associated with tertiles of EPA-DHA intake. Similarly, we observed an inverse association between fish consumption and serum FGF23 levels in adjusted analyses.

CONCLUSION

A higher intake of fish and dietary n-3 fatty acids (EPA-DHA) is related to lower circulating FGF23 levels in renal transplant recipients. Further research is needed to assess the causality of this association and the clinical implications.

Functional foods and cardiometabolic diseases* International Task Force for Prevention of Cardiometabolic Diseases

Mounting evidence supports the hypothesis that functional foods containing physiologically-active components may be healthful. Longitudinal cohort studies have shown that some food classes and dietary patterns are beneficial in primary prevention, and this has led to the identification of putative functional foods. This field, however, is at its very beginning, and additional research is necessary to substantiate the potential health benefit of foods for which the diet-health relationships are not yet scientifically validated. It appears essential, however, that before health claims are made for particular foods, in vivo randomized, double-blind, placebo controlled trials of clinical end-points are necessary to establish clinical efficacy. Since there is need for research work aimed at devising personalized diet based on genetic make-up, it seems more than reasonable the latter be modeled, at present, on the Mediterranean diet, given the large body of evidence of its healthful effects. The Mediterranean diet is a nutritional model whose origins go back to the traditional dietadopted in European countries bordering the Mediterranean sea, namely central and southern Italy, Greece and Spain; these populations have a lower incidence of cardiovascular diseases than the North American ones, whose diet is characterized by high intake of animal fat. The meeting in Naples and this document both aim to focus on the changes in time in these two different models of dietary habits and their fall out on public health.

Associations of plant and animal protein intake with 5-year changes in blood pressure: the Zutphen Elderly Study

BACKGROUND AND AIM

The aim of the present study was to investigate the association of plant and animal protein intake with 5-year changes in blood pressure (BP) level.

METHODS AND RESULTS

Analyses were based on 702 observations of 272 men participating in the Zutphen Elderly Study. Men did not use antihypertensive medication and were initially free of cardiovascular disease, diabetes mellitus and cancer. Physical and dietary examinations were performed in 1985, 1990, 1995, and 2000. Diet was assessed using the cross-check dietary history method. Men were categorised into tertiles according to their plant and animal protein intake. BP was measured twice at each examination. The associations of plant and animal protein intake with 5-year changes in BP level were investigated by a random intercept model with first-order autoregressive (AR [1]) serial correlation and a nugget effect. Adjustments were made for age, examination year, BMI, socioeconomic status, smoking, physical activity, prescribed diet, alcohol consumption and intake of energy and nutrients. In 1985, men were 70.1 ± 4.6 years old and had a mean BP of 147/84 mmHg. Mean protein intake was 15 en%, of which one-third consisted of plant protein. The higher-intake tertiles of plant protein intake were associated with a mean 5-year change of -2.9 mmHg (95% CI: -5.6, -0.2) systolic and -1.7 mmHg (95% CI: -3.2, -0.2) diastolic, compared with the lowest-intake tertile. No associations were observed for animal protein intake.

CONCLUSION

Intake of plant protein, but not animal protein, was inversely associated with 5-year changes in BP level in elderly men.

Diet quality and markers of endothelial function: the CARDIA study

BACKGROUND AND AIM

Dietary patterns are associated cross-sectionally with cellular adhesion molecules (CAMs). We studied prospective associations of three dietary patterns with CAMs.

METHODS AND RESULTS

In the Coronary Artery Risk Development in Young Adults (CARDIA) study, diet was assessed at years 0 (1985-86) and 7 (1992-93) examinations. Four circulating CAMs (E-selectin, P-selectin, soluble intercellular adhesion molecule 1 (sICAM-1), and vascular cellular adhesion molecule (VCAM)) were assayed at years 7 and 15 (2000-01). We created one index score "A Priori Diet Quality Score" and derived dietary patterns using principal components analysis (PCA). Multivariable linear regression models predicted year 15 CAMs from averaged (year 0/7) dietary patterns. The A Priori Diet Quality Score rated 46 food groups beneficial, neutral or adverse based on hypothesized health effects. We derived two PCA dietary patterns: "fruit and vegetables (FV)" (high intakes of fruit, vegetables, and whole grains) and "meat" (high intakes of red meat, refined grain, and butter). All dietary patterns were related to E-selectin and sICAM-1. P-selectin was not related to the FV dietary pattern. VCAM was only related to the A Priori Diet Quality Score. Strongest associations were for the meat dietary pattern with E-selectin (effect size 28% of an SD (+3.9/13.7 ng/mL)) and P-selectin (effect size 37% of an SD (+4.1/11.2 ng/mL)) and the A Priori Diet Quality Score with sICAM-1 (effect size 34% of an SD (-15.1/44.7 ng/mL)) and VCAM (effect size of 26% of an SD (-45.1/170.3 ng/mL)).

CONCLUSION

This prospective analysis suggests that dietary patterns are associated with CAMs.

N-6 and n-3 fatty acid cholesteryl esters in relation to incident stroke in a Dutch adult population: a nested case-control study

BACKGROUND AND AIMS

There are few prospective studies on fatty acid status in relation to incident stroke, with inconsistent results. We assessed the associations of plasma n-6 and n-3 PUFA in cholesteryl esters with the risk of total stroke and stroke subtypes in Dutch adults.

METHODS AND RESULTS

We conducted a nested case-control study using data from a population-based cohort study in adults aged 20-65 years. Blood sampling and data collection took place during 1993-1997 and subjects were followed for 8-13 years. We identified 179 incident cases of stroke and 179 randomly selected controls, matched on age, gender, and enrollment date. Odds ratios (OR) with 95% confidence intervals (95%CI) were calculated per standard deviation (SD) increase of PUFA in cholesteryl esters using multivariable conditional logistic regression. Cases comprised 93 ischemic, 50 hemorrhagic, and 36 unspecified strokes. The n-6 PUFA linoleic acid and arachidonic acid contributed ~55% and ~6.5% respectively to total plasma fatty acids, whereas the n-3 PUFA alpha-linolenic acid contributed ~0.5% and eicosapentaenoic acid plus docosahexaenoic acid (EPA-DHA) ~1.3%. After adjustment for confounders, n-6 and n-3 PUFA were not associated with incident total stroke or stroke subtypes. The OR (95% CI) for total stroke was 0.95 (0.74-1.23) per SD increase in linoleic acid and 1.02 (0.80-1.30) per SD increase in arachidonic acid. ORs (95% CI) for total stroke were 0.94 (0.72-1.21) for alpha-linolenic acid and 1.16 (0.94-1.45) for EPA-DHA.

CONCLUSION

In the present study, plasma n-6 or n-3 fatty acids were not related to incident stroke or stroke subtypes.

Cardiovascular risk management of hypertension and hypercholesterolaemia in the Netherlands: from unifactorial to multifactorial approach

About 30 years ago, the first Dutch unifactorial guidelines on hypertension and hypercholesterolaemia were developed. These guidelines have been revised several times, often after publication of landmark studies on new generations of drugs. In 1978, cut-off points for pharmacological treatment of hypertension were based on diastolic blood pressure values ≥115 mmHg, and in 2000 they were lowered to >100 mmHg. From 1997 onwards, cut-off points for systolic blood pressure values >180 mmHg were introduced, which became leading. In 1987, cut-offs for hypercholesterolaemia of ≥8 mmol/l were set and from 2006 pharmacological treatment was based on a total/HDL cholesterol ratio >8. Around 2000, treatment decisions for hypertension and/or hypercholesterolaemia were no longer based on high levels of individual risk factors, but on a multifactorial approach based on total risk of cardiovascular diseases (CVD), determined by a risk function. In the 2006 multidisciplinary guideline on cardiovascular risk management, the Framingham risk tables were replaced by European SCORE risk charts. A cut-off point of 10% CVD mortality was set in the Netherlands. In 2011, this cut-off point changed to 20% fatal plus nonfatal CVD risk. Nowadays, 'the lower the risk factors, the lower the absolute risk' is the leading paradigm in CVD prevention.

No effects of n-3 fatty acid supplementation on serum total testosterone levels in older men: the Alpha Omega Trial

The intake of the n-3 fatty acids alpha-linolenic acid (ALA), acid (EPA) and docosahexaenoic acid (DHA) has been related to testosterone levels in epidemiological analyses. The aim of this study was to assess whether the n-3 fatty acids affects testosterone levels in post-myocardial infarction (MI) patients, who are at risk of testosterone deficiency. In a double-blind, placebo-controlled trial of low-dose supplementation of n-3 fatty acids, we included 1850 male post-MI patients aged 60-80 years who participated in the Alpha Omega Trial. Patients were randomly allocated to margarines that provided 400 mg/day of EPA-DHA (n = 453), 2 mg/day of ALA (n = 467), EPA-DHA plus ALA (n = 458), or placebo (n = 472). Serum testosterone levels were assessed at baseline and after 41 months using whole day blood samples obtained at the subjects' home or at the hospital. Subjects were on average age of 68.4 (SD 5.3) years old and had baseline mean serum total testosterone of 14.8 (SD 5.6) nmol/L. The four randomized groups did not differ for baseline characteristics. ALA, EPA-DHA, and EPA-DHA plus ALA supplementation did not affect serum total testosterone compared to placebo. Moreover, n-3 fatty acid supplementation did not affect the risk of incident testosterone deficiency (n = 76 with total testosterone <8.0 nmol/L). We conclude that n-3 fatty acids supplementation did not affect serum total testosterone in men who had had a MI.

Levels and trends in cardiovascular risk factors and drug treatment in 4837 elderly Dutch myocardial infarction patients between 2002 and 2006

BACKGROUND: It is important to gain insight into opportunities for secondary prevention of cardiovascular disease. Our aim was to investigate levels and trends in cardiovascular risk factors and drug treatment in Dutch post-myocardial infarction (MI) patients between 2002 and 2006 and to make comparisons with the EUROASPIRE surveys (1999-2007). METHODS: We analysed data from 4837 post-MI patients (aged 69 years, 78% men) from 32 Dutch hospitals, using baseline cross-sectional data from the Alpha Omega Trial. RESULTS: Between 2002 and 2006, significant declines were found in the prevalence of smoking (23% to 16%, p < 0.001), hypercholesterolaemia (≥5 mmol/l; 54% to 27%, p < 0.0001) and hypertension (≥140/90 mmHg; 58% to 48%, p < 0.001). The prevalence of antithrombotic drugs was high (97%). The prevalence of lipid-modifying drugs and antihypertensives was high, and increased (74% to 90%, p < 0.0001 and 82% to 93%, p < 0.001, respectively). The prevalence of obesity (27%) was high in 2002 and decreased to 24% in 2006, albeit not significantly. Diabetes prevalence was high and increased between 2002 and 2006 (18% to 22%, p = 0.02). In comparison with EUROASPIRE patients, who were on average 8-10 years younger, our study in 2006 included patients with lower levels of obesity, hypertension, hypercholesterolaemia, diabetes and lower use of antiplatelets and β-blockers, but similar levels of lipid-modifying drugs. CONCLUSIONS: This study showed that older Dutch post-MI patients were adequately treated with drugs, and that risk factors reached lower levels than in the younger EUROASPIRE patients. However, there is room for improvement in diet and lifestyle, given the high prevalence of smoking, obesity, and diabetes.

Long-term wine consumption is related to cardiovascular mortality and life expectancy independently of moderate alcohol intake: the Zutphen Study

BACKGROUND

Light to moderate alcohol intake lowers the risk of cardiovascular mortality, but whether this protective effect can be attributed to a specific type of beverage remains unclear. Moreover, little is known about the effects of long-term alcohol intake on life expectancy.

METHODS

The impact of long-term alcohol intake and types of alcoholic beverages consumed on cardiovascular mortality and life expectancy at age 50 was investigated in the Zutphen Study, a cohort of 1373 men born between 1900 and 1920 and examined repeatedly between 1960 and 2000. Hazard ratios (HRs) for total alcohol intake and alcohol from wine, beer and spirits were obtained from time-dependent Cox regression models. Life expectancy at age 50 was calculated from areas under survival curves.

RESULTS

Long-term light alcohol intake, that is < or =20 g per day, compared with no alcohol, was strongly and inversely associated with cerebrovascular (HR 0.43, 95% CI 0.26 to 0.70), total cardiovascular (HR 0.70, 95% CI 0.55 to 0.89) and all-cause mortality (HR 0.75, 95% CI 0.63 to 0.91). Independent of total alcohol intake, long-term wine consumption of, on average, less than half a glass per day was strongly and inversely associated with coronary heart disease (HR 0.61, 95% CI 0.41 to 0.89), total cardiovascular (HR 0.68, 95% CI 0.53 to 0.86) and all-cause mortality (HR 0.73, 95% CI 0.62 to 0.87). These results could not be explained by differences in socioeconomic status. Life expectancy was about 5 years longer in men who consumed wine compared with those who did not use alcoholic beverages.

CONCLUSION

Long-term light alcohol intake lowered cardiovascular and all-cause mortality risk and increased life expectancy. Light wine consumption was associated with 5 years longer life expectancy; however, more studies are needed to verify this result.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Dietary intake of B(6-9-12) vitamins, serum homocysteine levels and their association with depressive symptoms: the Zutphen Elderly Study

OBJECTIVE

Low B-vitamin status and high levels of serum homocysteine are found in depressed inpatients, but results of population-based studies of this association are inconclusive. We investigated whether a low dietary intake of B(6-9-12) vitamins and high levels of serum homocysteine are associated with depressive symptoms in elderly men.

METHODS

The study sample included a total of 332 men aged 70-90 years who were free from cardiovascular diseases and diabetes at baseline in 1990. Depressive symptoms were measured with the Zung Self-rating Depression Scale at baseline in 1990 and dietary factors with the crosscheck dietary history method in 1985 and 1990. Serum levels of homocysteine were obtained in 1985. Multiple linear and logistic regression analyses were performed.

RESULTS

Dietary intake of folate (-1.19, 95% CI -2.03; -0.36) and vitamin B(6) (-2.09, 95% CI -2.92; -1.26) per standard deviation increase was associated with lower levels of serum homocysteine, while vitamin B(12) was not associated with serum homocysteine. Intake of folate, vitamin B(6), vitamin B(12) and levels of serum homocysteine were not related to depressive symptoms.

CONCLUSIONS

Our results do not support the hypothesis that a low dietary intake of B(6-9-12) vitamins and high levels of serum homocysteine are related to depression in healthy elderly men.

Decline in cognitive functioning is associated with a higher mortality risk

OBJECTIVE

This study investigates the association between 5-year change in cognitive functioning and subsequent mortality.

METHODS

Four hundred and ninety-three Dutch and Italian men from the Finland, Italy, and the Netherlands Elderly (FINE) Study, born between 1900 and 1920, participated in the present study between 1990 and 2000. Cognitive functioning was measured with the Mini-Mental State Examination in 1990 and 1995, and mortality data were obtained until the year 2000. A proportional hazard analysis was used to investigate the association between 5-year change in cognitive functioning and subsequent 5-year mortality. Adjustments were made for age, education, country, lifestyle factors, prevalence of chronic diseases and, additionally, for baseline cognitive functioning.

RESULTS

Men whose cognition decreased (more than 1 standard deviation) between 1990 and 1995 had a 2-fold higher risk of dying in the following 5 years compared with men whose cognition was stable (adjusted hazard ratio=1.9; 95% confidence interval 1.3-2.7). Mortality risk of men whose cognition improved between 1995 and 2000 was not different from men whose cognition was stable (adjusted hazard ratio=1.1, 95% confidence interval 0.7-1.9).

CONCLUSION

A decline in cognitive functioning is associated with a higher mortality risk.

Coffee consumption is inversely associated with cognitive decline in elderly European men: the FINE Study

OBJECTIVE

To investigate whether coffee consumption is associated with 10-year cognitive decline in elderly men, as results of previous studies obtained hitherto have been controversial and prospective information on this association has been lacking.

DESIGN, SUBJECTS AND SETTING

Six hundred and seventy six healthy men born between 1900 and 1920 from Finland, Italy and the Netherlands participated in a 10-year prospective cohort study. Cognitive functioning was assessed using the Mini-Mental State Examination (0-30 points, with a higher score indicating better cognitive performance). Coffee consumption was estimated in cups per day. A mixed longitudinal model was used to investigate the association between baseline coffee consumption and 10-year cognitive decline. Multiple adjustments were made.

RESULTS

Men who consumed coffee had a 10-year cognitive decline of 1.2 points (4%). Non-consumers had an additional decline of 1.4 points (P<0.001). An inverse and J-shaped association was observed between the number of cups of coffee consumed and cognitive decline, with the least cognitive decline for three cups of coffee per day (0.6 points). This decline was 4.3 times smaller than the decline of non-consumers (P<0.001).

CONCLUSIONS

Findings suggest that consuming coffee reduces cognitive decline in elderly men. An inverse and J-shaped association may exist between the number of cups of coffee consumed and cognitive decline, with the least cognitive decline for men consuming three cups of coffee per day.

Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review

BACKGROUND

Guidelines for lifestyle and dietary modification in patients with coronary artery disease (CAD) are mainly supported by evidence from general population studies. CAD patients, however, differ from the general population in age (older) and treatment with preventive drugs. This review seeks to provide evidence for a prognostic benefit of lifestyle and dietary recommendations from studies in CAD patients.

METHODS AND RESULTS

A literature search was performed on the effect of lifestyle and dietary changes on mortality in CAD patients. Prospective cohort studies and randomized controlled trials of patients with established CAD were included if they reported all-causes mortality and had at least 6 months of follow-up. The effect estimates of smoking cessation (relative risk [RR], 0.64; 95% CI, 0.58 to 0.71), increased physical activity (RR, 0.76; 95% CI, 0.59 to 0.98), and moderate alcohol use (RR, 0.80; 95% CI, 0.78 to 0.83) were studied most extensively. For the 6 dietary goals, data were too limited to provide reliable effect size estimates. Combinations of dietary changes were associated with reduced mortality (RR, 0.56; 95% CI, 0.42 to 0.74).

CONCLUSIONS

Available studies show convincingly the health benefits of lifestyle changes in CAD patients. Effect estimates of combined dietary changes look promising. Future studies should confirm these findings and assess the contribution of the individual dietary factors.

Interactions between five candidate genes and antihypertensive drug therapy on blood pressure

Despite the availability of effective antihypertensive drugs, there is a large variation in response to these drugs. This study investigates whether polymorphisms in the angiotensin converting enzyme (I/D), angiotensinogen (M235T), alpha-adducin (G460W), angiotensin II type 1 receptor (1166A/C), or G protein beta(3)-subunit (825C/T) gene modify the mean difference in blood pressure levels among diuretics, beta-blockers, or ACE-inhibitors users. Data were used from the Doetinchem Cohort Study, and blood pressure data were collected from GPs (1987-1997). A marginal generalized linear model (GEE) was used to assess the gene-drug interaction on the mean difference in systolic/diastolic blood pressure. In total, 625 hypertensive individuals were included with a total of 5262 measurements of blood pressure. Only the interaction between diuretic use and the GNB3 825C/T polymorphism was significant (C allele versus TT systolic blood pressure (SBP): 4.33 mmHg [95% CI: 0.14-8.54]). Thus, the mean SBP level among diuretic users may be modified by the GNB3 825C/T polymorphism.

Depression and long chain n-3 fatty acids in adipose tissue in adults from Crete

BACKGROUND

Only one study has investigated the relationship of essential fatty acids in the adipose tissue with depression in adults and suggested an inverse relationship between docosahexaenoic acid (22:6 n-3) (DHA) and depression.

OBJECTIVE

To examine the relation between adipose tissue polyunsaturated fatty acids especially n-3 and n-6 fatty acids, an index of long-term or habitual fatty acid intake, and depression in adults.

DESIGN

Cross-sectional study of healthy adults from the island of Crete.

SETTING

The Preventive Medicine and Nutrition Clinic, University of Crete, Greece.

SUBJECTS

A total of 130 healthy adults (59 males, 71 females) aged 22-58 years. The sample was a sub-sample of the Greek ApoEurope study group.

METHODS

Fatty acids were determined by gas chromatography in adipose tissue. Information about depression was obtained through the Zung Self-rating Depression Scale.

RESULTS

Adipose tissue DHA was inversely related with depression. Multiple linear regression analysis taking into account the possible confounding effect of age, gender, body mass index, smoking and educational level confirmed this association.

CONCLUSIONS

The inverse relationship between adipose DHA and depression in adults, replicates findings of a previous study. This relationship indicates that a low long-term dietary intake of DHA is associated with an increased risk for depression in adults.

Comparison of three different dietary scores in relation to 10-year mortality in elderly European subjects: the HALE project

OBJECTIVE

To investigate and compare the associations between dietary patterns and mortality using different European indexes of overall dietary quality.

DESIGN, SETTING AND PARTICIPANTS

The HALE (Healthy Ageing: a Longitudinal study in Europe) population includes 2,068 men and 1,049 women, aged between 70 and 90 years of 10 European countries. Subjects were followed for 10 years. This cohort study was conducted between 1988 and 2000.

RESULTS

During the follow-up period, 1,382 people died. The Mediterranean Diet Score (MDS) (HR: 0.82 with 95% CI: 0.75-0.91), the Mediterranean Adequacy Index (MDI) (HR: 0.83 with 95% CI: 0.75-0.92) and the Healthy Diet Indicator (HDI)(HR: 0.89 with 95% CI: 0.81-0.98) were inversely associated with all-causes mortality. Adjustments were made for age, gender, alcohol consumption, physical activity, smoking, number of years of education, body mass index, chronic diseases at baseline and study centre.

CONCLUSIONS

The MDS, the MDI and the HDI were significantly inversely related with mortality.

SPONSORSHIP

This study is based on data of the HALE project and supported by a grant from the European Union (QLK6-CT-2000-00211) to D Kromhout.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Netherlands Research programme weight Gain prevention (NHF-NRG): rationale, objectives and strategies

OBJECTIVE

To outline the rationale, objectives and strategies used in a systematically designed research programmme to study specific weight gain-inducing behaviours, their social-psychological as well as environmental determinants, and the effects of interventions aimed at the prevention of weight gain.

DESIGN

The evidence for potential behavioural determinants and strategies to prevent weight gain was reviewed, and the methods applied within the Netherlands Research programme weight gain prevention (NHF-NRG) project were described. The project is designed according to the Intervention Mapping protocol.

SETTING

The Netherlands.

SUBJECTS

The main target groups are (a) adolescents (12-16 y) in secondary school, (b) young adults (20-40 y) at the workplace and (c) recently retired people (55-65 y) at home.

INTERVENTIONS

Each intervention includes an individual component, in which computer-tailored information is provided. Additionally, interventions are aimed at changing environmental components.

RESULTS

The short-term results of this project can be expected by the beginning of 2005. Guidelines for nationwide weight gain prevention, based on this research programme, will become available in 2007.

CONCLUSIONS

Based on the few interventions that were evaluated to date, no robust conclusions can be drawn regarding the effectiveness of obesity prevention. The systematic and multidisciplinary design of the NHF-NRG programme enables the identification of potentially effective methods and strategies for the prevention of weight gain.

Physical activity in relation to cognitive decline in elderly men: The FINE Study

BACKGROUND

Physical activity may be associated with better cognition.

OBJECTIVE

To investigate whether change in duration and intensity of physical activity is associated with 10-year cognitive decline in elderly men.

METHODS

Data of 295 healthy survivors, born between 1900 and 1920, from the Finland, Italy, and the Netherlands Elderly (FINE) Study were used. From 1990 onward, physical activity was measured with a validated questionnaire for retired men and cognitive functioning with the Mini-Mental State Examination (maximum score 30 points).

RESULTS

The rates of cognitive decline did not differ among men with a high or low duration of activity at baseline. However, a decrease in activity duration of >60 min/day over 10 years resulted in a decline of 1.7 points (p < 0.0001). This decline was 2.6 times stronger than the decline of men who maintained their activity duration (p = 0.06). Men in the lowest intensity quartile at baseline had a 1.8 (p = 0.07) to 3.5 (p = 0.004) times stronger 10-year cognitive decline than those in the other quartiles. A decrease in intensity of physical activity of at least half a standard deviation was associated with a 3.6 times stronger decline than maintaining the level of intensity (p = 0.003).

CONCLUSIONS

Even in old age, participation in activities with at least a medium-low intensity may postpone cognitive decline. Moreover, a decrease in duration or intensity of physical activity results in a stronger cognitive decline than maintaining duration or intensity.

Prevalence and determinants of undertreatment of hypertension in the Netherlands

The objective of this study was to determine the prevalence, treatment, and control of hypertension, and the determinants of undertreatment in the Dutch population. The study design was cross-sectional. A population-based survey on cardiovascular disease risk factors in the Netherlands from 1996 to 2002 was the setting of the study. A total of 10 820 men and women, aged 30-59 years, were included in the study. The main outcome measures of the study were: Prevalence of hypertension, treatment, and control of hypertension and determinants of undertreatment of hypertension. Hypertension was defined as: systolic blood pressure (SBP) > or =140 mmHg and/or diastolic blood pressure (DBP) > or =90 mmHg, and/or the use of antihypertensive medication. Treated and controlled hypertension was defined as SBP <140 mmHg and DBP <90 mmHg. Multivariate logistic regression was used to assess the determinants of undertreatment. The prevalence of hypertension in men was 21.4% and in women 14.9%, and 17.9% of the hypertensive men and 38.5% of the hypertensive women were receiving antihypertensive medication. Of the untreated hypertensives, 21.9% of the men and 13.6% of the women were eligible for treatment with antihypertensive medication according to Dutch guidelines. Female gender and the use of cholesterol-lowering medication were associated with an increased chance of being treated. Subjects who were physically active, on a low salt diet, and current smokers had an increased chance of being untreated. Taking cholesterol-lowering medication and no asthma or allergy were factors associated with better control of blood pressure. In conclusion, a considerable proportion of hypertensives were untreated and uncontrolled. Therefore, the detection and control of hypertension in the Netherlands needs to improve. Several groups of hypertensives were identified that need additional care and attention.

Physical activity and stroke. A meta-analysis of observational data

BACKGROUND

Based on studies published so far, the protective effect of physical activity on stroke remains controversial. Specifically, there is a lack of insight into the sources of heterogeneity between studies.

METHODS

Meta-analysis of observational studies was used to quantify the relationship between physical activity and stroke and to explore sources of heterogeneity. In total, 31 relevant publications were included. Risk estimates and study characteristics were extracted from original studies and converted to a standard format for use in a central database.

RESULTS

Moderately intense physical activity compared with inactivity, showed a protective effect on total stroke for both occupational (RR = 0.64, 95% CI: 0.48-0.87) and leisure time physical activity (RR = 0.85, 95% CI: 0.78-0.93). High level occupational physical activity protected against ischaemic stroke compared with both moderate (RR = 0.77, 95% CI: 0.60-0.98) and inactive occupational levels (RR = 0.57, 95% CI: 0.43-0.77). High level compared with low level leisure time physical activity protected against total stroke (RR = 0.78, 95% CI: 0.71-0.85), haemorrhagic stroke (RR = 0.74, 95% CI: 0.57-0.96) as well as ischaemic stroke (RR = 0.79, 95% CI: 0.69-0.91). Studies conducted in Europe showed a stronger protective effect (RR = 0.47, 95% CI: 0.33-0.66) than studies conducted in the US (RR = 0.82, 95% CI: 0.75-0.90).

CONCLUSIONS

Lack of physical activity is a modifiable risk factor for both total stroke and stroke subtypes. Moderately intense physical activity is sufficient to achieve risk reduction.

Leisure time physical activity and health-related quality of life: cross-sectional and longitudinal associations

Studies that relate change in physical activity to change in health-related quality of life in the general population are needed to confirm associations suggested by cross-sectional studies. In the present study, cross-sectional as well as longitudinal associations between leisure time physical activity and health-related quality of life were studied in an apparently healthy population. The present study showed cross-sectional associations between at least moderately intense leisure time physical activity and general health perceptions, vitality, physical functioning and role limitations due to physical health problems. No associations were present for total leisure time physical activity. Change in leisure time physical activity was associated with change in social functioning in men as well as in women, irrespective of the intensity of physical activity. Only in men, change in total leisure time physical activity was associated with change in vitality and general mental health. In our study, cross-sectional associations were not confirmed by longitudinal analyses. Cross-sectional associations were mainly found for physical components of health-related quality of life, whereas longitudinal associations were predominantly observed for mental components of health-related quality of life. Confirmation of our results by those of other studies is needed in order to quantify health promotion messages.

Dietary intake of fatty acids and fish in relation to cognitive performance at middle age

OBJECTIVE

To examine the associations of fatty acid and fish intake with cognitive function.

METHODS

Data are from a cross-sectional population-based study among 1,613 subjects ranging from 45 to 70 years old. From 1995 until 2000, an extensive cognitive battery was administered and compound scores were constructed for memory, psychomotor speed, cognitive flexibility (i.e., higher order information processing), and overall cognition. A self-administered food-frequency questionnaire was used to assess habitual food consumption. The risk of impaired cognitive function (lowest 10% of the compound score) according to the energy adjusted intake of fatty acids was assessed with logistic regression, adjusting for age, sex, education, smoking, alcohol consumption, and energy intake.

RESULTS

Marine omega-3 polyunsaturated fatty acids (PUFA) (eicosapentaenoic acid and docosahexaenoic acid) were inversely related to the risk of impaired overall cognitive function and speed (per SD increase: OR = 0.81, 95% CI 0.66 to 1.00 and OR = 0.72, 95% CI 0.57 to 0.90). Results for fatty fish consumption were similarly inverse. Higher dietary cholesterol intake was significantly associated with an increased risk of impaired memory and flexibility (per SD increase: OR = 1.27, 95% CI 1.02 to 1.57 and OR = 1.26, 95% CI 1.01 to 1.57). Per SD increase in saturated fat intake, the risk of impaired memory, speed, and flexibility was also increased, although not significantly.

CONCLUSIONS

Fatty fish and marine omega-3 PUFA consumption was associated with a reduced risk and intake of cholesterol and saturated fat with an increased risk of impaired cognitive function in this middle-aged population.

Dietary flavonoids and cancer risk in the Zutphen Elderly Study

Flavonoids are polyphenolic antioxidants naturally present in vegetable foods. Some flavonoids, such as quercetin, inhibit carcinogenesis in rodents, but their effect in humans is unknown. We measured the flavonoids quercetin, kaempferol, myricetin, apigenin, and luteolin in foods and assessed flavonoid intake in 1985 by dietary history in 738 men aged 65-84 years without a history of cancer, who were then followed for five years. Mean flavonoid intake was 25.9 mg/day. The major sources of flavonoid intake were tea at 61% and vegetables and fruits (mainly onions, kale, endive, and apples) at 38%. Between 1985 and 1990, 75 men developed cancer (all sites) and 34 men died from cancer. Flavonoid intake in 1985 was not associated with incidence of all-cause cancer (p for trend = 0.54) or with mortality from all-cause cancer (p for trend = 0.51). Flavonoid intake was also not associated with risk of cancers of the alimentary and respiratory tract (p for trend = 0.92). Adjustment for age, body mass index, smoking, physical activity, and vitamin C, vitamin E, beta-carotene, and dietary fiber intake did not change the relative risks. A high intake of flavonoids from vegetables and fruits only was inversely associated with risk of cancer of the alimentary and respiratory tract (relative risk of highest vs. lowest tertile = 0.51, 95% confidence interval 0.25-1.05); these results suggest the presence of other nonvitamin components with anticarcinogenic potential in these foods. We conclude that intake of flavonoids, mainly from tea, apples, and onions, does not predict a reduced risk of all-cause cancer or of cancer of the alimentary and respiratory tract in elderly men. The effect of flavonoids on risk of cancer at specific sites needs further investigation in prospective cohort studies.

[Nutrition and health--unclear association between intake of vitamin E and the risk of coronary heart disease]

Vitamin E is a fat-soluble antioxidant and is possibly involved in the prevention of coronary heart disease by inhibiting oxidative modification of LDL cholesterol. The results of studies on the association between vitamin-E intake and coronary heart disease are inconsistent in observational studies and absent in large-scale intervention studies. This may be the consequence of confounding in observational studies and imperfections in the design of intervention trials. Another explanation is that vitamin E may only function protectively in the presence of sufficient co-antioxidants. At present, there is no evidence that vitamin E lowers the risk of coronary heart disease.

Twenty-five-year coronary mortality trends in the seven countries study using the accelerated failure time model

The 'accelerated failure time model' (AFT) was tested in the 25-year experience of the Seven Countries Study, to describe the shape of hazard for coronary heart disease (CHD) mortality during long-term follow-up. Sixteen cohorts of men aged 40-59 at entry were enrolled in eight countries (USA, Finland, The Netherlands, Italy, Croatia, Serbia, Greece and Japan) for a total of 12,763 subjects. Risk factors were measured and CHD mortality data collected during 25 years. The AFT incorporating the Weibull survival distribution was applied to the pooled cohorts of each country, with CHD mortality as endpoint. Cumulative hazards and the annual hazard for CHD mortality were estimated during 25 years and compared among countries. The annual hazard for CHD in 25 years tended to reduce relatively or flatten out in the northern American and northern European countries, exponentially increased in Serbia and Japan, and increased moderately in the other countries of southern Europe. Positive correlations were found between the shape of the hazard curve and population mean risk factor changes (serum cholesterol and systolic blood pressure) observed during the first 10 years follow-up. The Japanese group was an outlier. The countries with the largest relative decline in the annual hazard function were the same where, during the same historical period, the largest decreases in official death rates from CHD were recorded and vice versa. The curve shape in the annual hazard for CHD mortality in different countries seems related to changes in mean levels of serum cholesterol and systolic blood pressure.

Undertreatment of hypercholesterolaemia: a population-based study

AIMS

To assess the level of undertreatment of hypercholesterolaemia in the general population, taking intra-person variability in serum cholesterol concentrations into account, and to identify determinants of undertreatment of hypercholesterolaemia.

METHODS

In this cross-sectional study, data from two population-based surveys on cardiovascular disease risk factors conducted between 1987 and 1997 in the Netherlands were used. For all 64 757 respondents aged 20-59 years, treatment eligibility for lipid-lowering drug use was established according to the Dutch Cholesterol Consensus. Multivariate logistic models were used to identify determinants of undertreatment.

RESULTS

During the study period, 56.8% of the study population had undesirable cholesterol concentrations (serum total cholesterol> 5 mmol l(-1)) and 5.5% of those were eligible for pharmacological treatment based on their absolute risk of coronary heart disease. Of those eligible for pharmacological treatment, 16.3% were treated, and 19.6% of those treated had their serum total cholesterol concentration controlled. Only 3.2% of those eligible for pharmacological treatment were both treated and controlled. We identified several determinants for undertreatment, e.g. male gender and younger age for primary prevention and female gender and older age for secondary prevention. Treatment has improved slightly in more recent years.

CONCLUSIONS

Over 95% of the population eligible for the pharmacological treatment of hypercholesterolaemia was either untreated or was uncontrolled. To decrease undertreatment, identification of high-risk patients should be increased. Those who are treated with lipid-lowering medication could further benefit from more aggressive treatment, especially with statins.

[Nutrition and health--fish fatty acids against fatal coronary heart disease]

There are strong indications that eating (fatty) fish or n-3 fatty acids from fish reduces the risk of fata coronary heart disease (CHD). Observational studies in the general population show that consumption of moderate amounts of fish or n-3 fatty acids from fish are associated with a lower risk of fatal coronary heart disease and in particular sudden cardiac death. The most plausible hypothesis is that n-3 fatty acids reduce the risk of CHD mortality via anti-arrhythmic effects. Two clinical intervention trials show that prescription of fish or n-3 fatty acids to patients with prior myocardial infarction is effective in preventing mortality due to CHD. Ongoing trials will have to prove the effectiveness of a low dose of n-3 fatty acids and show that the underlying mechanism involves a protective effect against life-threatening arrhythmias. In addition to other recommendations for a healthier diet and lifestyle, consumption of one or two fatty fish meals a week is a highly effective and safe measure to reduce CHD mortality in both the general population and patients.

Long-term and recent time trends in the prevalence of obesity among Dutch men and women

OBJECTIVE

To describe long-term and recent time trends in the prevalence of obesity by age and educational level.

DESIGN

:Repeated cross-sectional population based monitoring studies.

SETTING

Consultation Bureau Heart Project 1976-1980, Monitoring Project on Cardiovascular Diseases 1987-1991 and Monitoring project on risk factors for chronic diseases (MORGEN-) project 1993-1997.

SUBJECTS

A total of 29 141 men and women aged 37-43 y (1976-1997); and 21 926 men and women aged 20-59 y (1993-1997).

MEASUREMENTS

Body mass index, ie weight divided by height squared.

RESULTS

Between 1976 and 1997 the prevalence of obesity increased from 4.9 to 8.5% among men and from 6.2 to 9.3% among women aged 37-43 y. Between 1993 and 1997, the prevalence of obesity among men aged 20-59 y was 8.5% and increased by 0.54 percentage points per year (P<0.01). The prevalence of obesity among women was 9.6% and increased by 0.35 percentage points per year (P=0.07). The increase in the prevalence of obesity in the period 1993-1997 was strongest in men with a relatively low educational level and in women with a high educational level.

CONCLUSIONS

There has been a steady increase in the prevalence of obesity in the last quarter of the 20th century. Also, a recent increase in the prevalence of obesity has been seen. To stop the increase in the prevalence of obesity, effective strategies for the management and prevention of obesity need to be developed.

Diet and 20-year chronic obstructive pulmonary disease mortality in middle-aged men from three European countries

OBJECTIVE

To investigate the relation of baseline antioxidant, fruit, vegetable and fish intake with 20 y chronic obstructive pulmonary disease (COPD) mortality in middle-aged men from three European countries.

DESIGN

Prospective study (1970-1990).

SETTING

Five population-based cohorts of middle-aged men from Finland, Italy and The Netherlands.

SUBJECTS

A total of 2917 men aged 50-69 y at baseline.

METHODS

Baseline information on diet was collected using the cross-check dietary history method. After 20 y of follow-up the underlying cause of death of those who died was established centrally. Survival analyses were performed using the Cox Proportional Hazards Model.

RESULTS

After adjustment for age, smoking and country, we observed an inverse trend (P-trend <0.05) of 20 y COPD mortality across tertiles of fruit and vitamin E intake. No trend was observed for vegetables, fish, vitamin C and beta-carotene. When modelled continuously, a 100 g increase in fruit intake was associated with a 24% lower COPD mortality risk (RR=0.76, 95% CI=0.60-0.92). For vitamin E intake (per 5 mg) the RR was 0.77 (95% CI=0.55-1.06), after adjustment for age, smoking and country. Additional adjustment for body mass index, total energy intake and alcohol consumption reduced the RR to 0.86 (95% CI=0.69-1.07, P=0.12) for fruit and 0.93 (95% CI=0.65-1.33) for vitamin E.

CONCLUSIONS

Our results suggest a protective effect of fruit and possibly vitamin E intake against COPD. No effect was observed for intake of vitamin C, beta-carotene, vegetables and fish.

Cardiovascular risk factors as determinants of 25-year all-cause mortality in the seven countries study

This analysis aims at describing all-cause mortality and their determinants in 16 cohorts of middle-aged men of eight nations. A total of 12,763 men aged 40-59 years were enrolled in the late 1950s and early 1960s in 16 cohorts located in the USA, Finland, The Netherlands, Italy, Croatia, Serbia, Greece and Japan. The highest death rates were found in Slavonia-Croatia, due to high rates of infectious diseases and violence (death rate of 610 per 1000), and in East Finland due to high rates from coronary heart disease (death rate of 597 per 1000). The lowest death rates were found in a highly educated group in Belgrade, Serbia (death rate 295 per 1000) and in Crete, Greece (death rate 314 per 1000). The ecological analysis showed no significant relationship between mean risk factor levels and all-cause death rates except for the direct association with systolic blood pressure during the first 15 years follow-up. Individual multivariate analysis on eight national pools showed that age, systolic blood pressure, and smoking habits are direct, significant, and universal long-term predictors of all-cause mortality. Serum cholesterol, physical activity and body mass index were so only in some areas. Multivariate coefficients were similar across nations. Pooled hazards ratios were 1.55 for a difference of 5 years of age (CI: 1.51-1.59); 1.23 for 10 cigarettes smoked per day (CI: 1.20-1.26); 0.91 for one unit (based on three grades) of physical activity score (CI: 0.87-0.95); 1.04 for 1 mmol/l of serum cholesterol (CI: 1.02-1.07); and 0.93 for three units of body mass index (CI: 0.91-0.96). In conclusion some cardiovascular risk factors predict long-term risk of all-cause mortality in different cultures.

Evolution of all-causes and cardiovascular mortality in the age-group 75-84 years in Europe during the period 1970-1996; a comparison with worldwide changes

BACKGROUND

In spite of the increase in longevity in the past century, studies of mortality patterns in elderly populations are scarce. We investigated cardiovascular and all-cause mortality patterns in age-group 75-84 years in Europe in the period 1970-1996. Methods Mortality data for the age-group 75-84 years were obtained from WHO and standardized according to the old European population standard. Tables were produced showing mortality rates per country around the year 1995 and trends were calculated over the period 1970-1996 using linear regression analysis. Results In both men and women aged 75-84 all-cause and cardiovascular mortality rates were higher in Central and Eastern Europe compared with Western Europe. For the last 3 available years, all-cause mortality rates differed by a factor 2/2.5 (men, women) when comparing the country with the highest with that of the lowest rate. For total cardiovascular mortality this factor was about 4/5 (men, women). During the period 1970-1996, all-cause and total cardiovascular mortality rates declined in most European countries. The decline in all causes of mortality was almost exclusively due to a decline in total cardiovascular disease mortality, especially stroke. Increases in total cardiovascular mortality were observed in some central European countries and Greece.

CONCLUSION

Major changes, mainly a decline, occurred in all-cause and cardiovascular mortality in subjects aged 75-84 in Europe. Therefore a passive attitude to health problems in the elderly is not warranted.

Body weight recovery, eating difficulties and compliance with dietary advice in the first year after stem cell transplantation: a prospective study

Among healthcare professionals there is no consensus about the best policy to increase oral intake and promote recovery in the post-hospital phase after bone marrow or blood stem cell transplantation. In order to evaluate body weight recovery and compliance with dietary advice among these patients, we performed a prospective longitudinal study in the first year post transplant. At five time intervals (days 50, 75, 125, 200 and 350) patients received a nutritional questionnaire with items on nutrition-related symptoms, physical condition, body weight recovery and compliance with dietary advice. From the initial cohort of 135 patients 69 completed the study. Prevalence of eating difficulties was high (66% at day 50). Anorexia, dry mouth, altered taste, nausea and tiredness were the symptoms most strongly associated with eating difficulties. Compliance with dietary advice was poor. Conditioning regimen was found to be a prognostic factor for body weight status at day 350. In more than 50% of the TBI-treated patients body weight was not restored to 95% of the pretreatment value within 1 year after transplant. Future studies should focus on increasing energy and protein intake in the TBI-treated subgroup.