P6234The relationship of alcohol consumption with risk factors of coronary heart disease and the intake of macro- and micro-nutrients in Japanese: the INTERLIPID study

Background

Many studies have reported the J-shaped relationship between alcohol consumption and coronary heart disease (CHD) risk; therefore, light-drinkers is generally recognized to be associated with the lower risk of CHD. However, the mechanisms of lower risk for CHD in light-drinkers are still unclear. Alcohol drinking status is likely to be associated with not only CHD risk factors but also dietary intake. Nevertheless, few studies report these relationships in detail.

Purpose

The purpose of this study is to evaluate the relationships of alcohol drinking status with CHD classical risk factors and the intake of macro- and micro- nutrients in Japanese.

Methods

Study participants were 1,090 Japanese men and women aged 40–59 years from The INTERLIPID study excepted for 55 individuals who had missing data (n=26) and were past-drinkers (n=29). Alcohol consumption was assessed with two 7-day alcohol records, and average ethanol intake (per week) was calculated. Participants were classified into following 4 groups: non-drinkers (0g/week), light-drinkers (<100 g/week), moderate-drinkers (100–299 g/week), and heavy-drinkers (≥300 g/week). Serum LDL and HDL cholesterol, blood pressure (BP), the prevalence of hypertension and dyslipidemia, and smoking status were assessed as CHD risk factors. The intake of energy and macro- and micro-nutrients were evaluated from the four-timed in-depth 24-hr dietary recalls. Nutrient intake densities were calculated per total energy intake without alcohol. The analysis of variance and chi-squared test were used to evaluate the relations of alcohol status with CHD risk factors and nutrient intake.

Results

Serum HDL cholesterol levels increased and LDL cholesterol levels decreased with increasing alcohol consumption. Systolic and diastolic BP increased with increasing alcohol consumption. J-shaped relationships with alcohol consumption were observed for the proportion of current smoker, number of cigarettes, and the prevalence of hypertension; that is, light-drinkers was lowest among all groups. The prevalence of dyslipidemia was the highest in non-drinkers, and decreased with increasing alcohol consumption. In heavy-drinkers, total energy (kcal/day) was the highest, but energy intake without alcohol (kcal/day) was the lowest. For macronutrients, the intake of carbohydrate (%kcal) decreased, and the intakes of total and animal protein (%kcal) increased with increasing alcohol consumption. The intakes of total cholesterol (mg/1000kcal) and sodium (mg/1000kcal) increased, and total fiber (g/1000kcal) decreased with increasing alcohol consumption. These associations were similar in men and women.

Conclusions

Alcohol consumption was related with not only CHD classical risk factors but also the intake of macro- and micro-nutrients. Non-drinkers had a higher proportion of some CHD risk factors than light-drinkers. These results might influence on J-shaped relationship between alcohol consumption and CHD risk.

Acknowledgement/Funding

1: Ministry of Education, Science, Sports, and Culture of Japan, 2: National Institutes of Health, Bethesda, MD, USA

Relation of raw and cooked vegetable consumption to blood pressure: the INTERMAP Study

Inverse associations have been reported of overall vegetable intake to blood pressure (BP); whether such relations prevail for both raw and cooked vegetables has not been examined. Here we report cross-sectional associations of vegetable intakes with BP for 2195 Americans ages 40-59 in the International Study of Macro/Micronutrients and Blood Pressure (INTERMAP) using four standardized multi-pass 24-h dietary recalls and eight BP measurements. Relations to BP of raw and cooked vegetables consumption, and main individual constituents were assessed by multiple linear regression. Intakes of both total raw and total cooked vegetables considered separately were inversely related to BP in multivariate-adjusted models. Estimated average systolic BP differences associated with two s.d. differences in raw vegetable intake (68 g per 1000 kcal) and cooked vegetable intake (92 g per 1000 kcal) were -1.9 mm Hg (95% confidence interval (CI): -3.1, -0.8; P=0.001) and -1.3 mm Hg (95% CI: -2.5, -0.2; P=0.03) without body mass index (BMI) in the full model; -1.3 mm Hg (95% CI: -2.4, -0.2; P=0.02) and -0.9 mm Hg (95% CI: -2.0, 0.2; P=0.1) with additional adjustment for BMI. Among commonly consumed individual raw vegetables, tomatoes, carrots, and scallions related significantly inversely to BP. Among commonly eaten cooked vegetables, tomatoes, peas, celery, and scallions related significantly inversely to BP.

Relation of dietary and lifestyle traits to difference in serum leptin of Japanese in Japan and Hawaii: the INTERLIPID study

BACKGROUND AND AIMS

Previously, we found significantly higher serum leptin in Japanese-Americans in Hawaii than Japanese in Japan. We investigated whether differences in dietary and other lifestyle factors explain higher serum leptin concentrations in Japanese living a Western lifestyle in Hawaii compared with Japanese in Japan.

METHODS AND RESULTS

Serum leptin and nutrient intakes were examined by standardized methods in men and women ages 40-59 years from two population samples, one Japanese-American in Hawaii (88 men, 94 women), the other Japanese in central Japan (123 men, 111 women). Multiple linear regression models were used to assess role of dietary and other lifestyle traits in accounting for serum leptin difference between Hawaii and Japan. Mean leptin was significantly higher in Hawaii than Japan (7.2 ± 6.8 vs 3.7 ± 2.3 ng/ml in men, P < 0.0001; 12.8 ± 6.6 vs 8.5 ± 5.0 in women <0.0001). In men, higher BMI in Hawaii explained over 90% of the difference in serum leptin; in women, only 47%. In multiple linear regression analyses in women, further adjustment for physical activity and dietary factors--alcohol, dietary fiber, iron--produced a further reduction in the coefficient for the difference, total reduction 70.7%; P-value for the Hawaii-Japan difference became 0.126.

CONCLUSION

The significantly higher mean leptin concentration in Hawaii than Japan may be attributable largely to differences in BMI. Differences in nutrient intake in the two samples were associated with only modest relationship to the leptin difference.

Dietary intake and urinary excretion of selenium in the Japanese adult population: the INTERMAP Study Japan

OBJECTIVE

This study is to examine the relationship between dietary selenium intake and 24-h urinary selenium excretion in Japanese population samples participating in the INTERMAP Study.

METHODS

Using highly standardized methods, we assessed individual dietary selenium intake from four 24-h dietary recalls and measured urinary selenium excretion in two timed 24-h urine collections in 1145 Japanese participants (574 men and 571 women) ages 40-59 years in four areas of Japan.

RESULTS

The medians of dietary selenium intake were 177.5 microg/day in men and 139.8 microg/day in women; the medians of 24-h urinary selenium excretion were 127.9 microg/day in men and 109.4 microg/day in women, that is, urinary excretion was estimated to be 73% of dietary intake in men and 77% in women. Dietary selenium intake was significantly correlated with 24-h urinary selenium excretion (r=0.24 in men, r=0.18 in women; P<0.001). With dietary selenium intake and urinary selenium excretion expressed per kg of body weight, values were similar for men and women (dietary intake, 2.7 microg/kg body weight in men and 2.5 microg/kg body weight in women; urinary excretion, 2.0 microg/kg body weight in men and 2.0 microg/kg body weight in women).

CONCLUSION

Dietary intake and 24-h urinary excretion of selenium are related in the Japanese adult population.

Dietary intake in male and female smokers, ex-smokers, and never smokers: the INTERMAP study

This report examines dietary intakes in smokers, ex-smokers, and never smokers in INTERMAP. The 4680 participants aged 40-59 years-from 17 population samples in four countries (China, Japan, UK, USA)-provided four 24-h recalls to assess nutrient intakes and two 24-h urine collections to assess excretion of urea, sodium (Na), potassium (K), etc. Compared to never smokers, current smokers generally consumed more energy from alcohol and saturated fats (SFA), less energy from vegetable protein and carbohydrates, less dietary fibre, vitamin E, beta carotene, vitamin C, thiamine, riboflavin, folate, vitamin B6, calcium, iron, phosphorus, magnesium (Mg), and K per 1000 kcal, excreted less K and urea (marker of dietary protein), had a lower ratio of polyunsaturated fat (PFA) to SFA intake, higher Keys dietary lipid score, and higher dietary and urinary Na/K. There were few differences between smokers and never smokers for total energy intake, energy from total and animal protein, monounsaturated fats, PFA, omega 3 and omega 6 PFA, dietary cholesterol, total vitamin A, retinol, vitamin D, vitamin B12, and urinary and dietary Na. Compared to ex-smokers, smokers generally consumed less energy from vegetable protein, omega 3 PFA, carbohydrates, less dietary fibre, beta carotene, vitamin E, vitamin C, thiamine, riboflavin, folate, vitamin B6, iron, phosphorus, Mg, had lower PFA/SFA, and excreted less urea and K. In conclusion, INTERMAP results are consistent with other reports indicating that smokers have less healthful diets than nonsmokers. Public health interventions in smokers should focus not only on helping them to quit smoking but also on improving their diets to further reduce cancer and cardiovascular disease risks.

Higher blood pressure in middle-aged American adults with less education-role of multiple dietary factors: the INTERMAP study

Extensive evidence exists that an inverse relation between education and blood pressure prevails in many adult populations, but little research has been carried out on reasons for this finding. A prior goal of the INTERMAP Study was to investigate this phenomenon further, and to assess the role of dietary factors in accounting for it. Of the 4680 men and women aged 40-59 years, from 17 diverse population samples in Japan, People's Republic of China, UK, and USA, a strong significant inverse education-BP relation was manifest particularly for the 2195 USA participants, independent of ethnicity. With participants stratified by years of education, and assessment of 100+ dietary variables from four 24-h dietary recalls and two 24-h urine collections/person, graded relationships were found between education and intake of many macro- and micronutrients, electrolytes, fibre, and body mass index (BMI). In multiple linear regression analyses with systolic BP (SBP) and diastolic BP (DBP) of individuals the dependent variables (controlled for ethnicity, other possible nondietary confounders), BMI markedly reduced size of education-BP relations, more so for women than for men. Several nutrients considered singly further decreased size of this association by > or =10%: urinary 24-h Na and K excretion, Keys dietary lipid score, vegetable protein, fibre, vitamins C and B6, thiamin, riboflavin, folate, calcium, magnesium, and iron. Combinations of these dietary variables and BMI attenuated the education-SBP inverse coefficient by 54-58%, and the education-DBP inverse coefficient by 59-67%, with over half these effects attributable to specific nutrients (independent of BMI). As a result, the inverse education-BP coefficients ceased to be statistically significant. Multiple specific dietary factors together with body mass largely account for the more adverse BP levels of less educated than more educated Americans. Special efforts to improve eating patterns of less educated strata can contribute importantly to overcoming this and related health disparities in the population.

Diet for preventing cardiovascular diseases: light from Ancel Keys, distinguished centenarian scientist

On the great occasion of Professor Ancel Keys' 100th birthday (26 January,2004), it is particularly appropriate--and highly relevant for today and tomorrow--to note the highlights of his professional accomplishments and contributions: the Seven Countries Study (SCS) he initiated and led demonstrated unequivocally in its cross-population analyses that dietary saturated fat intake significantly influences serum cholesterol and the risk of coronary heart disease (CHD), and in turn serum cholesterol relates to CHD risk. In SCS analyses on the several thousand individual participants, it further showed that serum cholesterol, blood pressure, and cigarette smoking all have a continuous, graded, strong, independent, predictive relation to long-term CHD. These data have been critically invaluable for the definition of the major coronary risk factors and low risk status. In scores of metabolic ward feeding trials, Keys and colleagues also demonstrated that dietary saturates and cholesterol relate positively to serum cholesterol, polyunsaturates inversely, and they derived the predictive equation bearing Keys' name. They further showed that increased dietary fiber and weight loss by obese people contribute to reduction of serum cholesterol. All these data served importantly for the development of sound public policy for CHD prevention, and Keys--along with many colleagues all over the world whom he trained and inspired--pioneered in the struggle to achieve and apply that policy in modern public health and medical care.

INTERMAP: the dietary data--process and quality control

The aim of this report is to describe INTERMAP standardized procedures for assessing dietary intake of 4680 individuals from 17 population samples in China, Japan, UK and USA: Based on a common Protocol and Manuals of Operations, standardized collection by centrally trained certified staff of four 24 h dietary recalls, two timed 24-h urines, two 7-day histories of daily alcohol intake per participant; tape recording of all dietary interviews, and use of multiple methods for ongoing quality control of dietary data collection and processing (local, national, and international); one central laboratory for urine analyses; review, update, expansion of available databases for four countries to produce comparable data on 76 nutrients for all reported foods; use of these databases at international coordinating centres to compute nutrient composition. Chinese participants reported 2257 foods; Japanese, 2931; and UK, 3963. In US, use was made of 17,000 food items in the online automated Nutrition Data System. Average time/recall ranged from 22 min for China to 31 min for UK. Among indicators of dietary data quality, coding error rates (from recoding 10% random samples of recalls) were 2.3% for China, 1.4% for Japan, and UK; an analogous US procedure (re-entry of recalls into computer from tape recordings) also yielded low discrepancy rates. Average scores on assessment of taped dietary interviews were high, 40.4 (Japan) to 45.3 (China) (highest possible score: 48); correlations between urinary and dietary nutrient values--similar for men and women--were, for all 4680 participants, 0.51 for total protein, range across countries 0.40-0.52; 0.55 for potassium, range 0.30-0.58; 0.42 for sodium, range 0.33-0.46. The updated dietary databases are valuable international resources. Dietary quality control procedures yielded data generally indicative of high quality performance in the four countries. These procedures were time consuming. Ongoing recoding of random samples of recalls is deemed essential. Use of tape recorded dietary interviews contributed to quality control, despite feasibility problems, deemed remediable by protocol modification. For quality assessment, use of correlation data on dietary and urinary nutrient values yielded meaningful findings, including evidence of special difficulties in assessing sodium intake by dietary methods.

Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study

The purpose of the study was to compare nutrient intakes among Chinese, Japanese, UK, and US INTERMAP samples, and assess possible relationships of dietary patterns to differential patterns of cardiovascular diseases between East Asian and Western countries. Based on a common Protocol and Manuals of Operations, high-quality dietary data were collected by four standardized 24-h dietary recalls and two 24-h urine collections from 17 population samples in China (three samples), Japan (four samples), UK (two samples), and USA (eight samples). There were about 260 men and women aged 40-59 years per sample--total N=4680. Quality of dietary interview and data entry were monitored and enhanced by extensive systematic ongoing quality control procedures at local, country, and international level. Four databases on nutrient composition of foods from the four countries were updated and enhanced (76 nutrients for all four countries) by the Nutrition Coordinating Center, University of Minnesota, in cooperation with Country Nutritionists. The mean body mass index was much higher for Western than East Asian samples. Macronutrient intakes differed markedly across these samples, with Western diet higher in total fat, saturated and trans fatty acids, and Keys dietary lipid score, lower in total carbohydrate and starch, higher in sugars. Based on extensive published data, it is a reasonable inference that this pattern relates to higher average levels of serum total cholesterol and higher mortality from coronary heart disease in Western than East Asian populations. The rural Chinese diet was lower in protein, especially animal protein, in calcium, phosphorus, selenium, and vitamin A. Dietary sodium was higher, potassium lower, hence Na/K ratio was higher in the Asian diet, especially for Chinese samples. This pattern is known to relate to risks of adverse blood pressure level and stroke. At the end of the 20th century, East Asian and Western diets remain significantly different in macro- and micronutrient composition. Both dietary patterns have aspects that can be regarded, respectively, as adverse and protective in relation to the major adult cardiovascular diseases. In both Asian and Western countries, public efforts should be targeted at overcoming adverse aspects and maintaining protective patterns for prevention and control of cardiovascular diseases.

INTERMAP: background, aims, design, methods, and descriptive statistics (nondietary)

Blood pressure (BP) above optimal (< or =120/< or =80 mmHg) is established as a major cardiovascular disease (CVD) risk factor. Prevalence of adverse BP is high in most adult populations; until recently research has been sparse on reasons for this. Since the 1980s, epidemiologic studies confirmed that salt, alcohol intake, and body mass relate directly to BP; dietary potassium, inversely. Several other nutrients also probably influence BP. The DASH feeding trials demonstrated that with the multiple modifications in the DASH combination diet, SBP/DBP (SBP: systolic blood pressure, DBP: diastolic blood pressure) was sizably reduced, independent of calorie balance, alcohol intake, and BP reduction with decreased dietary salt. A key challenge for research is to elucidate specific nutrients accounting for this effect. The general aim of the study was to clarify influences of multiple nutrients on SBP/DBP of individuals over and above effects of Na, K, alcohol, and body mass. Specific aims were, in a cross-sectional epidemiologic study of 4680 men and women aged 40-59 years from 17 diverse population samples in China, Japan, UK, and USA, test 10 prior hypotheses on relations of macronutrients to SBP/DBP and on role of dietary factors in inverse associations of education with BP; test four related subgroup hypotheses; explore associations with SBP/DBP of multiple other nutrients, urinary metabolites, and foods. For these purposes, for all 4680 participants, with standardized high-quality methods, assess individual intake of 76 nutrients from four 24-h dietary recalls/person; measure in two timed 24-h urine collections/person 24-h excretion of Na, K, Ca, Mg, creatinine, amino acids; microalbuminuria; multiple nutrients and metabolites by nuclear magnetic resonance and high-pressure liquid chromatography. Based on eight SBP/DBP measurements/person, and data on multiple possible confounders, utilize mainly multiple linear regression and quantile analyses to test prior hypotheses and explore relations of multiple dietary and urinary variables to SBP/DBP of individuals. The 4680 INTERMAP participants are equally divided across four age/gender strata: diverse in ethnicity, education, occupation, physical activity; use of cigarettes, alcohol; diagnosed high BP, CVD, diabetes; CVD family history; women vary in parity, use of contraceptive medication and hormone replacement therapy.

Serum cholesterol changes from 1983-1984 to 1993-1994 in the People's Republic of China

BACKGROUND AND AIM

Increasing cardiovascular disease (CVD) mortality in the People's Republic of China (PRC) led to the 1981 establishment of the PRC-USA Study of Cardiovascular and Cardiopulmonary Epidemiology which, among other objectives, is concerned with the correlates of CVD morbidity and mortality in Chinese populations among other objectives. This report describes changes in total cholesterol (TC) levels in four PRC populations from 1983 to 1993 and identifies factors related to the changes.

METHODS AND RESULTS

Population screenings carried out in 1983-1984, 1987-1988 and 1993-1994 involved the collection of demographic data, specimens (including blood), medical history and physical examination data. The data from cohort and independent samples were used to assess TC changes in urban and rural men and women over the decade, with and without adjustment for age and body mass index (BMI) changes. For Guangzhou men and women, the cohort analyses (aged 35-54 at baseline) showed increases in TC of 10-20 mg/dL after adjustment for age and changes in BMI; the independent sample analyses (aged 35-44) also showed higher average TC levels in 1993-1994 than in 1983-1984. For the Beijing cohorts, the results showed decreases in TC during the decade in men, an increase in TC in urban women and no change in rural women; the independent sample analyses indicated declines in TC for Beijing men and women. Possible reasons for the Guangzhou TC increases are economic growth, and dietary and BMI changes. The mean age-adjusted BMI significantly increased (5-10%) over the 10-year period in all of the studied groups.

CONCLUSIONS

TC increased 10-20 mg/dL in Guangzhou men and women, probably as a result of socioeconomic development during the decade. The inconsistent patterns of TC changes in Beijing require further study.

Pulse pressure compared with other blood pressure indexes in the prediction of 25-year cardiovascular and all-cause mortality rates: The Chicago Heart Association Detection Project in Industry Study

We compared the relations of 4 blood pressure (BP) indexes (pulse pressure [PP], systolic BP [SBP], diastolic BP [DBP], and mean arterial pressure [MAP]) with 25-year mortality rates for coronary heart disease (CHD), cardiovascular disease (CVD), and all causes in younger, middle-aged, and older men and women by using data from a long-term prospective epidemiological study of employed persons who were screened between 1967 and 1973. A single supine BP measurement was obtained at baseline. Vital status was determined through 1995. We report on 5 groups (total, 28 360 participants) consisting of men age 18 to 39, 40 to 59, and 60 to 74 years and of women age 40 to 59 and 60 to 74 years who were not receiving antihypertensive treatment, had no history of CHD, and did not have diabetes. Cox proportional hazards analyses were used to determine multivariate-adjusted hazard ratios with a 1-SD higher value for each BP index; Wald chi(2) tests were used to compare the strength of relations. Relations of PP were less strong than were those of SBP for all end points in all age/gender groups. SBP or MAP showed the strongest relations to all end points in all age/gender groups (hazard ratio, 1.17 to 1.36). The relations of SBP to death were stronger than were those of DBP, except for middle-aged men and for CVD in women. DBP showed significant positive associations with death, after control for SBP, in middle-aged participants. In conclusion, these data indicate that the long-term risk of high BP should be assessed mainly on the basis of SBP or of SBP and DBP together, not on the basis of PP, in apparently healthy adults.

Relationship of blood pressure to 25-year mortality due to coronary heart disease, cardiovascular diseases, and all causes in young adult men: the Chicago Heart Association Detection Project in Industry

BACKGROUND

Data are limited on blood pressure (BP) in young adults and long-term mortality. Moreover, screening and hypertension treatment guidelines have been based mainly on findings for middle-aged and older populations. This study assesses relationships of BP measured in young adult men to long-term mortality due to coronary heart disease (CHD), cardiovascular diseases (CVD), and all causes.

METHODS

This cohort from the Chicago Heart Association Detection Project in Industry included 10 874 men aged 18 to 39 years at baseline (1967-1973), not receiving antihypertensive drugs, and without CHD or diabetes. Relationship of baseline BP to 25-year CHD, CVD, and all-cause mortality was assessed.

RESULTS

Age-adjusted association of systolic BP to CHD mortality was continuous and graded. Multivariate-adjusted CHD hazard ratios (HRs) for 1 SD higher systolic BP (15 mm Hg) and diastolic BP (10 mm Hg) were 1.26 (95% confidence interval [CI], 1.11-1.44) and 1.17 (95% CI, 1.01-1.35), respectively. Compared with the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure stratum with normal BP (and lowest mortality rates), the large strata with high-normal BP and stage 1 hypertension had 25-year absolute risks for death of 63 and 72 per 1000, respectively, and absolute excess risks of 10 and 20 per 1000, respectively; accounted for 59.8% of all excess CHD, CVD, and all-cause mortality; and were estimated to have life expectancy shortened by 2.2 and 4.1 years, respectively.

CONCLUSIONS

In young adult men, BP above normal was significantly related to increased long-term mortality due to CHD, CVD, and all causes. Population-wide primary prevention, early detection, and control of higher BP are indicated from young adulthood on.

Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention

A workshop was held September 27 through 29, 1999, to address issues relating to national trends in mortality and morbidity from cardiovascular diseases; the apparent slowing of declines in mortality from cardiovascular diseases; levels and trends in risk factors for cardiovascular diseases; disparities in cardiovascular diseases by race/ethnicity, socioeconomic status, and geography; trends in cardiovascular disease preventive and treatment services; and strategies for efforts to reduce cardiovascular diseases overall and to reduce disparities among subpopulations. The conference concluded that coronary heart disease mortality is still declining in the United States as a whole, although perhaps at a slower rate than in the 1980s; that stroke mortality rates have declined little, if at all, since 1990; and that there are striking differences in cardiovascular death rates by race/ethnicity, socioeconomic status, and geography. Trends in risk factors are consistent with a slowing of the decline in mortality; there has been little recent progress in risk factors such as smoking, physical inactivity, and hypertension control. There are increasing levels of obesity and type 2 diabetes, with major differences among subpopulations. There is considerable activity in population-wide prevention, primary prevention for higher risk people, and secondary prevention, but wide disparities exist among groups on the basis of socioeconomic status and geography, pointing to major gaps in efforts to use available, proven approaches to control cardiovascular diseases. Recommendations for strategies to attain the year 2010 health objectives were made.

Associations of weight change and weight variability with cardiovascular and all-cause mortality in the Chicago Western Electric Company Study

Few studies of associations between weight loss or weight fluctuations and mortality have been sufficiently long term to permit exclusion of early deaths for a portion of follow-up long enough to eliminate likely effects of illness-related weight loss. This study examined associations of the variation (standard deviation and standard deviation about the trend (slope)) and trend (weight loss or weight gain) in body mass index (weight (kg)/height (m2) between 1958 and 1966 (minimum of five measurements) with subsequent 25-year mortality among 1,281 men originally aged 40-56 years from the Chicago Western Electric Company Study. In multivariate Cox regression models that included two slope variables representing weight loss and weight gain and each variability measure separately, weight loss and weight gain were significantly related to 15-year mortality but weight variability was not. Relative risks for cardiovascular disease mortality were 1.25 (95% confidence interval (CI): 1.09, 1.45) and 1.14 (95% CI: 0.97, 1.33), respectively, for weight loss and weight gain slopes larger by 0.12 kg/m2 per year; corresponding relative risks for all-cause mortality were 1.23 (95% CI: 1.10, 1.38) and 1.15 (95% CI: 1.03, 1.29), respectively. For follow-up years 16-25, none of these weight variables were significantly related to mortality. These results indicate that an association between weight loss and mortality may not persist beyond 15 years, and that weight variability may not be related to mortality independently of weight loss or weight gain.

Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP)

CONTEXT

The Systolic Hypertension in the Elderly Program (SHEP) demonstrated that treating isolated systolic hypertension in older patients decreased incidence of total stroke, but whether all types of stroke were reduced was not evaluated.

OBJECTIVE

To investigate antihypertensive drug treatment effects on incidence of stroke by type and subtype, timing of strokes, case-fatality rates, stroke residual effects, and relationship of attained systolic blood pressure to stroke incidence.

DESIGN

The SHEP study, a randomized, double-blind, placebo-controlled trial began March 1, 1985, and had an average follow-up of 4.5 years.

SETTING AND PARTICIPANTS

A total of 4736 men and women aged 60 years or older with isolated systolic hypertension at 16 clinical centers in the United States.

INTERVENTIONS

Patients were randomly assigned to receive treatment with 12.5 mg/d of chlorthalidone (step 1); either 25 mg/d of atenolol or 0.05 mg/d of reserpine (step 2) could be added (n = 2365); or placebo (n = 2371).

MAIN OUTCOME MEASURES

Occurrence, type and subtype, and timing of first strokes and stroke fatalities; and change in stroke incidence for participants (whether in active treatment or placebo groups) reaching study-specific systolic blood pressure goal (decrease of at least 20 mm Hg from baseline to below 160 mm Hg) compared with participants not reaching goal.

RESULTS

A total of 85 and 132 participants in the active treatment and placebo groups, respectively, had ischemic strokes (adjusted relative risk [RR], 0.63; 95% confidence interval [CI], 0.48-0.82); 9 and 19 had hemorrhagic strokes (adjusted RR, 0.46; 95% CI, 0.21-1.02); and 9 and 8 had strokes of unknown type (adjusted RR, 1.05; 95% CI, 0.40-2. 73), respectively. Four subtypes of ischemic stroke were observed in active treatment and placebo group participants, respectively, as follows: for lacunar, n = 23 and n = 43 (adjusted RR, 0.53; 95% CI, 0.32-0.88); for embolic, n = 9 and n = 16 (adjusted RR, 0.56; 95% CI, 0.25-1.27); for atherosclerotic, n = 13 and n = 13 (adjusted RR, 0. 99; 95% CI, 0.46-2.15); and for unknown subtype, n = 40 and n = 60 (adjusted RR, 0.64; 95% CI, 0.43-0.96). Treatment effect was observed within 1 year for hemorrhagic strokes but was not seen until the second year for ischemic strokes. Stroke incidence significantly decreased in participants attaining study-specific systolic blood pressure goals.

CONCLUSIONS

In this study, antihypertensive drug treatment reduced the incidence of both hemorrhagic and ischemic (including lacunar) strokes. Reduction in stroke incidence occurred when specific systolic blood pressure goals were attained. JAMA. 2000;284:465-471

Relationship of baseline serum cholesterol levels in 3 large cohorts of younger men to long-term coronary, cardiovascular, and all-cause mortality and to longevity

CONTEXT

Based on observational and interventional data for middle-aged cohorts (aged 40-64 years), serum cholesterol level is known to be an established major risk factor for coronary heart disease (CHD). However, findings for younger people are limited, and the value of detecting and treating hypercholesterolemia in younger adults is debated.

OBJECTIVE

To evaluate the long-term impact of unfavorable serum cholesterol levels on risk of death from CHD, cardiovascular disease (CVD), and all causes.

DESIGN, SETTING, AND PARTICIPANTS

Three prospective studies, from which were selected 3 cohorts of younger men with baseline serum cholesterol level measurements and no history of diabetes mellitus or myocardial infarction. A total of 11,017 men aged 18 through 39 years screened in 1967-1973 for the Chicago Heart Association Detection Project in Industry (CHA); 1266 men aged 25 through 39 years examined in 1959-1963 in the Peoples Gas Company Study (PG); and 69,205 men aged 35 through 39 years screened in 1973-1975 for the Multiple Risk Factor Intervention Trial (MRFIT).

MAIN OUTCOME MEASURES

Cause-specific mortality during 25 (CHA), 34 (PG), and 16 (MRFIT) years of follow-up; mortality risks; and estimated life expectancy in relation to baseline serum cholesterol levels.

RESULTS

Death due to CHD accounted for 26%, 34%, and 28% of all deaths in the CHA, PG, and MRFIT cohorts, respectively; and CVD death for 34%, 42%, and 39% of deaths in the same cohorts, respectively. Men in all 3 cohorts with unfavorable serum cholesterol levels (200-239 mg/dL [5.17-6.18 mmol/L] and >/=240 mg/dL [>/=6.21 mmol/L]) had strong gradients of relative mortality risk. For men with serum cholesterol levels of 240 mg/dL or greater (>/=6.21 mmol/L) vs favorable levels (<200 mg/dL [<5.17 mmol/L]), CHD mortality risk was 2.15 to 3.63 times greater; CVD disease mortality risk was 2.10 to 2.87 times greater; and all-cause mortality was 1.31 to 1.49 times greater. Hypercholesterolemic men had age-adjusted absolute risk of CHD death of 59 per 1000 men in 25 years (CHA cohort), 90 per 1000 men in 34 years (PG cohort), and 15 per 1000 men in 16 years (MRFIT cohort). Absolute excess risk was 43.6 per 1000 men (CHA), 81.4 per 1000 men (PG), and 12.1 per 1000 men (MRFIT). Men with favorable baseline serum cholesterol levels had an estimated greater life expectancy of 3.8 to 8.7 years.

CONCLUSIONS

These results demonstrate a continuous, graded relationship of serum cholesterol level to long-term risk of CHD, CVD, and all-cause mortality, substantial absolute risk and absolute excess risk of CHD and CVD death for younger men with elevated serum cholesterol levels, and longer estimated life expectancy for younger men with favorable serum cholesterol levels. JAMA. 2000;284:311-318

Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS): baseline characteristics and comparison with USA population

BACKGROUND

Results of the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) demonstrated that treatment with lovastatin, in addition to modifications of diet and lifestyle, reduced the rate of first acute major coronary events compared with placebo in a cohort that included participants with average to mildly elevated total levels of cholesterol, and below average levels of high-density lipoprotein cholesterol, women, and elderly subjects.

OBJECTIVE

To describe the baseline characteristics of the study's cohort.

DESIGN

This was a double-blind, placebo-controlled, primary-prevention trial in which Americans with average to mildly elevated total levels of cholesterol [4.65-6.83 mmol/l (180-264 mg/dl)] and no clinical evidence of atherosclerotic cardiovascular disease were randomly allocated either 20-40 mg/day lovastatin or placebo in addition to a low-saturated fat, low-cholesterol diet. Baseline characteristics of the study cohort are described, and the characteristics of a USA reference population based upon NHANES III data are provided for comparison.

RESULTS

The study includes 5608 men (85%) and 997 women (15%) with mean total cholesterol level 5.71 +/- 0.54 mmol/l (221 +/- 21 mg/dl), low-density lipoprotein cholesterol level 3.88 +/- 0.44 mmol/l (150 +/- 17 mg/dl), high-density lipoprotein cholesterol 0.96 +/- 0.15 mmol/l (37 +/- 6 mg/dl), and median triglyceride level 1.78 +/- 0.86 mmol/l (158 +/- 76 mg/dl). The mean age is 58 years (ranges 45-73 years for men and 55- 73 years for women). The participants are 89% white, 7% Hispanic, and 3% black.

CONCLUSION

Results from AFCAPS/TexCAPS will be applicable to large segments of populations; in the USA alone, eight million share the demographic and baseline-lipid-level characteristics of the study cohort.

Relation of low body mass to death and stroke in the systolic hypertension in the elderly program. The SHEP Cooperative Research Group

BACKGROUND

There are scant data on the effect of body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) on cardiovascular events and death in older patients with hypertension.

OBJECTIVE

To determine if low body mass in older patients with hypertension confers an increased risk of death or stroke.

PATIENTS

Participants were 3975 men and women (mean age, 71 years) enrolled in 17 US centers in the Systolic Hypertension in the Elderly Program trial, a randomized, double-blind, placebo-controlled clinical trial of lowdose antihypertensive therapy, with follow-up for 5 years.

MAIN OUTCOME MEASURES

Five-year adjusted mortality and stroke rates from Cox proportional hazards analyses.

RESULTS

There was no statistically significant relation of death or stroke with BMI in the placebo group (P = .47), and there was a U- or J-shaped relation in the treatment group. The J-shaped relation of death with BMI in the treated group (P = .03) showed that the lowest probability of death for men was associated with a BMI of 26.0 and for women with a BMI of 29.6; the curve was quite flat for women across a wide range of BMIs. For stroke, men and women did not differ, and the BMI nadir for both sexes combined was 29, with risk increasing steeply at BMIs below 24. Those in active treatment, however, had lower death and stroke rates compared with those taking placebo.

CONCLUSIONS

Among older patients with hypertension, a wide range of BMIs was associated with a similar risk of death and stroke; a low BMI was associated with increased risk. Lean, older patients with hypertension in treatment should be monitored carefully for additional risk factors.

Comparison of electrocardiographic findings between Northern and Southern Chinese population samples

BACKGROUND

Cardiovascular disease is rare in China, but there are few data on the prevalence of electrocardiographic (ECG) abnormalities in Chinese populations.

METHODS

The ECG surveys were carried out in four Chinese population samples, in a total of 9,666 adults aged 35-54 in Beijing and Guangzhou, China from 1981 to 1984. Twelve-lead resting ECG tracings were coded by the Minnesota Code.

RESULTS

Prevalence per 1,000 of abnormal ECG ranged from 77.4 to 209.8, and was higher for men than women and higher for Guangzhou than Beijing. Prevalence per 1,000 of major abnormalities in Guangzhou was 29.8 for men and 78.4 for women, higher than the 18.4 and 29.6 for counterparts in Beijing. The ECG changes attributed in 'Western' populations to coronary heart disease (CHD), such as large Q waves (Minnesota Code 1-1, 1-2) and ST-T abnormalities, were similar between Beijing and Guangzhou men, but Guangzhou women had much higher prevalence of ST-T abnormalities than Beijing women. Other ECG abnormalities such as A-V block, left branch bundle block, and left ventricular hypertrophy were rare in people of both sites.

CONCLUSIONS

Compared with similar data from the US, these Chinese populations had a relatively low prevalence of ECG abnormalities putatively related to CHD. This corresponds with the low incidence of CHD in the Chinese population. However, within the Chinese populations of this study, a high abnormality rate appeared in a population with low incidence of CHD and hypertension (Guangzhou women). Reasons why ECG abnormalities do not parallel prevalence levels of CHD and hypertension remain to be elucidated.

Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women

CONTEXT

Three major coronary risk factors-serum cholesterol level, blood pressure, and smoking-increase incidence of coronary heart disease (CHD) and related end points. In previous investigations, risks for low-risk reference groups were estimated statistically because samples contained too few such people to measure risk.

OBJECTIVE

To measure long-term mortality rates for individuals with favorable levels for all 3 major risk factors, compared with others.

DESIGN

Two prospective studies, involving 5 cohorts based on age and sex, that enrolled persons with a range of risk factors. Low risk was defined as serum cholesterol level less than 5.17 mmol/L (<200 mg/dL), blood pressure less than orequal to 120/80 mm Hg, and no current cigarette smoking. All persons with a history of diabetes, myocardial infarction (MI), or, in 3 of 5 cohorts, electrocardiogram (ECG) abnormalities, were excluded.

SETTING AND PARTICIPANTS

In 18 US cities, a total of 72144 men aged 35 through 39 years and 270671 men aged 40 through 57 years screened (1973-1975) for the Multiple Risk Factor Intervention Trial (MRFIT); in Chicago, a total of 10025 men aged 18 through 39 years, 7490 men aged 40 through 59 years, and 6229 women aged 40 through 59 years screened (1967-1973) for the Chicago Heart Association Detection Project in Industry (CHA) (N = 366559).

MAIN OUTCOME MEASURES

Cause-specific mortality during 16 (MRFIT) and 22 (CHA) years, relative risks (RRs) of death, and estimated greater life expectancy, comparing low-risk subcohorts vs others by age strata.

RESULTS

Low-risk persons comprised only 4.8% to 9.9% of the cohorts. All 5 low-risk groups experienced significantly and markedly lower CHD and cardiovascular disease death rates than those who had elevated cholesterol level, or blood pressure, or smoked. For example, age-adjusted RRs of CHD mortality ranged from 0.08 for CHA men aged 18 to 39 years to 0.23 for CHA men aged 40 through 59 years. The age-adjusted relative risks (RRs) for all cardiovascular disease mortality ranged from 0.15 for MRFIT men aged 35 through 39 years to 0.28 for CHA men aged 40 through 59 years. The age-adjusted RR for all-cause mortality rate ranged from 0.42 for CHA men aged 40 through 59 years to 0.60 for CHA women aged 40 through 59 years. Estimated greater life expectancy for low-risk groups ranged from 5.8 years for CHA women aged 40 through 59 years to 9.5 years for CHA men aged 18 through 39 years.

CONCLUSIONS

Based on these very large cohort studies, for individuals with favorable levels of cholesterol and blood pressure who do not smoke and do not have diabetes, MI, or ECG abnormalities, long-term mortality is much lower and longevity is much greater. A substantial increase in the proportion of the population at lifetime low risk could contribute decisively to ending the CHD epidemic.

Resting heart rate is a risk factor for cardiovascular and noncardiovascular mortality: the Chicago Heart Association Detection Project in Industry

In a prospective cohort study, associations of resting heart rate with risk of coronary, cardiovascular disease, cancer, and all-cause mortality in age-specific cohorts of black and white men and women were examined over 22 years of follow-up. Participants were employees from 84 companies and organizations in the Chicago, Illinois, area who volunteered for a screening examination. Participants included 9,706 men aged 18-39 years, 7,760 men aged 40-59 years, 1,321 men aged 60-74 years, 6,928 women aged 18-39 years, 6,915 women aged 40-59 years, and 1,151 women aged 60-74 years at the baseline examination in 1967-1973. Vital status was ascertained through 1992. For fatal coronary disease, multivariate-adjusted relative risks associated with a 12 beats per minute higher heart rate (one standard deviation) were as follows: for men aged 18-39 years, relative risk (RR) = 1.27 (95% confidence interval (CI) 1.08-1.48); for men aged 40-59 years, RR = 1.13 (95% CI 1.05-1.21); for men aged 60-74 years, RR = 1.00 (95% CI 0.89-1.12); for women aged 40-59 years, RR = 1.21 (95% CI 1.07-1.36); and for women aged 60-74 years, RR = 1.16 (95% CI 0.99-1.37). Corresponding risks for all fatal cardiovascular diseases were similar to those for coronary death alone. Deaths from cancer were significantly associated with heart rate in men and women aged 40-59 years. All-cause mortality was associated with higher heart rate in men aged 18-39 years (RR = 1.11, 95% CI 1.01-1.20), men aged 40-59 years (RR = 1.16, 95% CI 1.11-1.21), and women aged 40-59 years (RR = 1.20, 95% CI 1.13-1.27). Heart rate was not associated with mortality in women aged 18-39 years. In summary, heart rate was a risk factor for mortality from coronary disease, all cardiovascular diseases, and all causes in younger men and in middle-aged men and women, and for cancer mortality in middle-aged men and women.

Prospective analysis of traits related to 6-year change in sodium-lithium countertransport. Gubbio Population Study Research Group

Sodium-lithium countertransport (Na-Li CT) activity in red blood cells relates cross-sectionally and longitudinally to blood pressure and hypertension. Lifestyle and metabolic factors relate cross-sectionally to this sodium transporter. The aim of this study was to conduct a prospective analysis of 6-year Na-Li CT change and of traits related to Na-Li CT change. In 2183 participants in the Gubbio Population Study (972 men and 1211 women; baseline ages, 18 to 74 years), the following data collected at baseline and 6-year follow-up were analyzed: Na-Li CT; gender; age; body mass index (BMI); blood pressure; antihypertensive treatment; alcohol intake; smoking habits; urinary sodium-to-potassium ratio; and plasma cholesterol, glucose, uric acid, sodium, potassium, and triglycerides (measured only at follow-up). Six-year changes were defined as follow-up minus baseline values. Na-Li CT was higher at follow-up than at baseline in both genders (P<0.001). Baseline Na-Li CT; baseline and change values of BMI; and change values of alcohol intake, plasma potassium, and plasma glucose related to Na-Li CT change significantly and independently with control for other variables. Follow-up plasma triglyceride levels also related independently to Na-Li CT change. Coefficients were positive for BMI, alcohol intake, and plasma glucose and triglyceride levels and were negative for baseline Na-Li CT and plasma potassium levels. Baseline and change values of other variables did not relate significantly to Na-Li CT change. In conclusion, in prospective analyses, BMI, alcohol intake, plasma glucose, and lipids were directly related to Na-Li CT change; baseline Na-Li CT and plasma potassium levels were inversely related. The data support the concept that lifestyle and related metabolic factors influence Na-Li CT.

Association of nonspecific minor ST-T abnormalities with cardiovascular mortality: the Chicago Western Electric Study

CONTEXT

Minor electrocardiographic (ECG) ST-T abnormalities are common, but their prognostic importance has not been fully determined.

OBJECTIVE

To examine associations of single (1 time only) and multiple (2 times only and > or =3 times) nonspecific minor ST-T abnormalities in 5 years with long-term mortality due to myocardial infarction (MI), coronary heart disease (CHD), cardiovascular disease (CVD), and all causes in middle-aged men.

DESIGN

Prospective cohort study (29-year follow-up after 5 annual examinations).

SETTING AND PARTICIPANTS

A total of 1673 men employed at the Western Electric Company in Chicago, III, aged 40 to 55 years at entry, with no evidence of CHD and no major ECG abnormalities throughout the first 5-year period.

MAIN OUTCOME MEASURES

Minor ST-T abnormalities identified from annual resting ECGs and mortality ascertained from death certificates.

RESULTS

Of the 1673 men, 173 had evidence of isolated nonspecific minor ST-T segment abnormalities. During the follow-up period, there were 234 deaths due to MI, 352 deaths due to CHD, 463 deaths due to CVD, and 889 deaths due to all causes. For men with 3 or more annual recordings of minor ST-T abnormalities, risk of death due to MI, CHD, CVD, and all causes was significantly greater than for those with normal ECG findings. For men with 3 or more ECGs with minor ST-T abnormalities, relative risks (and 95% confidence intervals) adjusted for cardiovascular and other risk factors were 2.28 (1.16-4.49), 2.39 (1.39-4.12), 2.30 (1.44-3.68), and 1.60 (1.06-2.42), respectively, with a graded relationship between frequency of occurrence of ST-T abnormalities and mortality risk (linear trend, P< or =.007).

CONCLUSIONS

Persistent, minor, nonspecific ST-T abnormalities are associated with increased long-term risk of mortality due to MI, CHD, CVD, and all causes; the higher the frequency of occurrence of minor ST-T abnormalities, the greater the risk. These data underscore the potential value of including nonspecific ECG findings in the overall assessment of cardiovascular risk.

Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs

BACKGROUND

People without major risk factors for cardiovascular disease in middle age live longer than those with unfavorable risk-factor profiles. It is not known whether such low-risk status also results in lower expenditures for medical care at older ages. We used data from the Chicago Heart Association Detection Project in Industry to assess the relation of a low risk of cardiovascular disease in middle age to Medicare expenditures later in life.

METHODS

We studied 7039 men and 6757 women who were 40 to 64 years of age when surveyed between 1967 and 1973 and who survived to have at least two years of Medicare coverage in 1984 through 1994. Men and women classified as being at low risk for cardiovascular disease were those who had the following characteristics at the time they were initially surveyed: serum cholesterol level, <200 mg per deciliter (5.2 mmol per liter); blood pressure, < or =120/80 mm Hg; no current smoking; an absence of electrocardiographic abnormalities; no history of diabetes; and no history of myocardial infarction. We compared Medicare costs for the 279 men (4.0 percent) and 298 women (4.4 percent) who had this low-risk profile with those for the rest of the study group, who were not at low risk. Health Care Financing Administration charges for services to Medicare beneficiaries were used to estimate average annual health care costs (total costs, those for cardiovascular diseases, and those for cancer).

RESULTS

Average annual health care charges were much lower for persons at low risk - the total charges for the men at low risk were less than two thirds of the charges for the men not at low risk ($1,615 less); for the women at low risk, the charges were less than one half of those for the women not at low risk ($1,885 less). Charges related to cardiovascular disease were lower for the low-risk groups of men and women than for those not at low risk (by $979 and $556, respectively), and charges related to cancer were also lower (by $134 and $189).

CONCLUSIONS

People with favorable cardiovascular risk profiles in middle age had lower average annual Medicare charges in older age. Having optimal status with respect to major cardiovascular risk factors may result not only in greater longevity but also in lower health care costs.