P6222Changes in main CVD risk factors in Finland 1992–2017

Background

Systematic monitoring of cardiovascular disease (CVD) risk factors started in eastern Finland already in the 1970s as part of the North Karelia Project. Later on risk factor monitoring was extended to other parts of the country.

Purpose

In this study we report the trends of main CVD risk factors in Finland from 1992 to 2017.

Methods

Study population consists of a population-based random sample of 31 402 men and women aged 25–64 years who participated in the FINRISK Studies from 1992 to 2012, and in the FinHealth Study in 2017. Data collection was done every five years. Participation rate decreased from 76% in 1992 to 56% in 2017. Study protocol included self-reported questionnaire data on smoking and other health behavior, measurements of height, weight and blood pressure, and venous blood sample for laboratory analysis. Blood pressure was measured two times, and the average of the measurements was calculated, total serum cholesterol was analyzed using enzymatic method, and LDL cholesterol was calculated using Friedewald formula.

Results

Smoking prevalence, mean blood pressure and total and LDL cholesterol levels declined markedly during the 25 year follow up but BMI, waist circumference and prevalence of obesity increased (table).

CVD risk factor change from 1992 to 2017 Risk factor Men 1992 Men 2017 p value Women 1992 Women 2017 p value Smoking (%) 36.7 20.6 <0.001 25.9 16.5 <0.001 SBP (mmHg) 136.6 131.2 <0.001 130.3 124.5 <0.001 DBP (mmHg) 82.7 81.6 <0.001 78.6 77.8 <0.001 Chol (mmol/L) 5.66 5.17 <0.001 5.42 5.18 <0.001 LDL chol (mmol/L) 3.54 3.16 <0.001 3.26 3.03 <0.001 BMI (kg/m2) 26.2 27.2 <0.001 25.1 26.4 <0.001 WC (cm) 92.8 96.1 <0.001 79.2 86.2 <0.001 Obesity (%) 15.7 23.2 <0.001 14.8 22.7 <0.001

Conclusions

The levels of main traditional CVD risk factors have markedly decreased among the Finnish population during the last 25 years but in the same time, obesity has become a major public health challenge.

Former male elite athletes have better metabolic health in late life than their controls

Elite-class athletes have longer life expectancy and lower risk for chronic noncommunicable diseases possibly because of physically active and healthier lifestyle. In this study, we assessed former male Finnish elite-class athletes' (n = 392) and their matched controls' (n = 207) body composition, and risk for the metabolic syndrome (MS) and nonalcoholic fatty liver disease (NAFLD) in later life. Compared with the controls, the former athletes had lower body fat percentage (24.8% vs 26.0%, P = 0.021), lower risk for MS [odds ratio (OR) 0.57, 95% confidence interval (CI) 0.40-0.81], and NAFLD (OR 0.61, 95% CI 0.42-0.88). High volume of current leisure-time physical activity (LTPA) was associated with lower body fat percentage (P for trend < 0.001). When current volume of LTPA increased 1 MET h/week, the risk of MS and NAFLD decreased (OR 0.99, 95% CI 0.98-0.99 and OR 0.97, 95% CI 0.96-0.98, respectively). Although a career as an elite-class athlete during young adulthood may help to protect from developing metabolic syndrome, present exercise levels and volume of LTPA seem equally important as well.

Ageing and associations of fasting plasma glucose and 2 h plasma glucose with HbA(1C) in apparently healthy population. "FIN-D2D" study

OBJECTIVE

In this FIN-D2D cross-sectional survey the relationship of age with HbA(1c) and fasting and 2h glucose in the oral glucose tolerance test (OGTT) was explored in apparently randomly selected healthy population.

PATIENTS AND METHODS

The glycaemic parameters were measured in 1344 men and 1482 women (aged 45-74 years), and among them we excluded all subjects with known diabetes, hypertension or dyslipidaemia. The final analyses for HbA(1c) and the ratios of fasting glucose/HbA(1c) and 2h glucose/HbA(1c) included 649 men and 804 women.

RESULTS

Mean age was 57 years and BMI 26.1kg/m(2) for both genders. HbA(1c) increased in both genders with age (p<0.001). For a particular fasting glucose level HbA(1c) level was higher in older age groups (p<0.001 for linearity). By contrast, a particular 2h plasma glucose value in OGTT implied significantly lower HbA(1c) in the elderly (p<0.001 for linearity).

CONCLUSION

In apparently healthy population, screened with OGTT, in older individuals compared with younger ones a particular HbA(1c) value implies slightly lower fasting glucose, but relatively higher 2h glucose. These results need to be verified in different populations. The effects of age on relation between HbA(1c) and plasma glucose should be taken into account in classifying people into different dysglycaemia categories.

Determinants of risk factors of atherosclerosis in the postinfarction period: The Tallinn MI Study

Environmental as well as genetic factors are involved in the pathogenesis of myocardial infarction. The disease is a frequent cause of mortality in the middle-aged male population of Estonia. The high prevalence of premature myocardial infarction (PMI) in this country is not fully understood. The association of atherogenic and thrombogenetic risk factors with lifestyle was evaluated in men who had suffered myocardial infarction at 55 years of age (n = 71) and in randomly selected corresponding controls (n = 85). Serum routine lipids, apolipoprotein (apo)A-I, apoB, apoE polymorphism, lipoprotein(a) and fibrinogen levels were determined. Behavioural risk factors, indices of obesity, blood pressure and pedigree data were registered. In 80.6 % of PMI subjects some type of hyperlipidaemia was observed (European Atherosclerosis Society Classification) and lipid-lowering drugs were taken by 13.9 % of patients. In PMI patients the most common positive determinants of atherogenic lipoprotein indices were waist-to-hip ratio and physical inactivity, and in controls, waist-to-hip ratio and apoE phenotype. The odds ratio (OR) of PMI was 8.9-fold greater in the highest tertile of apoB/apoA-I distribution compared with the lowest tertile. The OR of PMI in the highest tertile of fibrinogen distribution versus the lowest tertile was 6.2 (95 % CI 2.46-15.44), and OR of PMI in the highest Lp(a) tertile versus the lowest was 3.1 (95 % CI 1.31-7.40). Thus, atherogenic dyslipidaemia was the most serious cardiovascular risk factor among PMI patients. From two thrombogenesis-related markers, the levels of fibrinogen and Lp(a), the first one was more strongly associated with PMI status.

Serum lipid and apolipoprotein profiles in newborns and six‐year‐old children: The Tallinn Young Family Study

Seventy children aged 6 years (34 boys, 36 girls) were studied for cardiovascular risk factors. Among the children 40 had also been investigated at birth. The aim of the study was to determine changes in serum lipoprotein parameters from birth up to preschool age and to assess the role of some relevant factors that might affect the process. An obvious association was found between serum apolipoprotein (apo) B levels, the apoB/apoA-I ratio and lipoprotein(a) (Lp(a)) levels at birth and at 6 years of age (r = 0.43; p<0.05, r = 0.73; p<0.0001 and r = 0.81; p<0.0001, respectively). Thirty percent of children who were in the top quartile by apoB or total cholesterol levels and 66.7% of those in this quartile by apoB/apoA-I ratio at birth remained in the top quartiles also in the follow-up study. The significantly higher apoB/apoA-I ratio in newborns and the apoB/apoA-I and apoB values in the 6-year-old children were observed in the carrier apoE4 isoform as compared to E3 homozygotes. A significant influence of apoE polymorphism on serum apoB/apoA-I ratio and apoB level in preschool children was confirmed by ANOVA one-way analysis of variance. In a multiple regression analysis from all the studied factors, the independent determinants of apoB level in preschool age were apoE phenotype, gestational age and Apgar score in the first minute of life. Thus, tracking of serum Lp(a), apoB, apoB/apoA-I ratio and total cholesterol levels from birth up to 6 years of age was demonstrated. The association between apoE polymorphism and serum lipoprotein parameters became more obvious after the first 6 years of life.

Serum alpha- and gamma-tocopherol concentrations and risk of advanced beta cell autoimmunity in children with HLA-conferred susceptibility to type 1 diabetes mellitus

AIMS/HYPOTHESIS

The aim of our study was to assess the associations of serum alpha- and gamma-tocopherol concentrations with the risk of advanced beta cell autoimmunity in children with HLA-conferred genetic susceptibility to type 1 diabetes mellitus.

METHODS

A case-control study with 108 cases with advanced beta cell autoimmunity and 216 matched control participants nested within the birth cohort of the Type 1 Diabetes Prediction and Prevention Project. A serum sample for vitamin E analyses was collected from all the children in the cohort at the age of 1 year and thereafter at 12 month intervals. For each case-control group, all the repeated serum samples up to the age of seroconversion to autoantibody positivity in the case were analysed. A conditional logistic regression model was used to determine potential associations between seroconversion and serum tocopherol concentrations.

RESULTS

Serum alpha- or gamma-tocopherol concentrations were not significantly associated with the risk of advanced beta cell autoimmunity. The odds ratio (95% CI) for micromol/l increase in serum concentration of the first-year sample was 0.97 (0.92-1.03) for alpha-tocopherol and 1.10 (0.70-1.74) for gamma-tocopherol. However, there was an interaction between high values of gamma-tocopherol at the age of 1 year and the time of seroconversion (p = 0.024).

CONCLUSIONS/INTERPRETATION

It seems unlikely that high concentrations of alpha- or gamma-tocopherol protect against advanced beta cell autoimmunity in young children.

Measurement of blood glucose: comparison between different types of specimens

Aim

To provide conversion formulae between measurements based on different specimens in use in epidemiological studies and clinical practice, and to evaluate the relative precision for the different methods.

Background

The current guidelines emphasize the use of venous plasma for determining glucose concentration. Nevertheless, the World Health Organization (WHO) guidelines provide cut-off points for different specimens for the determination of the glucose concentration in circulating blood (venous plasma, whole blood, serum and capillary blood). There is a lack of data about the comparability between the values obtained by using different specimens.

Methods

Eleven different combinations of specimens and methods of measurement of blood glucose were used in 294 blood samples from 74 subjects. The methods were grouped by the specimen used for analysis (venous plasma, whole blood, serum and capillary blood).

Results

The result of the analysis is a set of linear equations allowing conversion of the result from one specimen or method to another. Furthermore, it was estimated how much of the variation for each method can be attributed to laboratory variance.

Conclusions

Measurements based on capillary blood had a very large variability compared with other methods. Measurements based on venous whole blood tended to give results 0.5 mmol/L lower than other methods. Our data indicate that the current diagnostic cut-off points, as recommended by WHO for non-plasma specimens, are not fully compatible and may differ as much as 0.5 mmol/L between specimens.

Long-term effects of fenofibrate on VLDL and HDL subspecies in participants with type 2 diabetes mellitus

AIMS/HYPOTHESIS

Low HDL-cholesterol (HDL-C) is frequently accompanied by high triacylglycerol levels in diabetic dyslipidaemia, increasing the risk of CHD. In the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, fenofibrate treatment lowered triacylglycerol levels, but the initial 5% increase in HDL-C attenuated over 5 years. We explored the changes in VLDL and HDL subspecies during fenofibrate treatment in a statin-free FIELD cohort.

METHODS

We randomised 171 participants with type 2 diabetes mellitus, who had been recruited to the FIELD study in Helsinki, to micronised fenofibrate (200 mg/day) or placebo in double-blind study design. VLDL and HDL subspecies were separated by ultracentrifugation at baseline and at the second and fifth year. Apolipoprotein (apo)A-I and apoA-II were measured by immunoturbidometric methods and lipoprotein (Lp)A-I and LpAI-AII particles by differential immunoassay.

RESULTS

Fenofibrate reduced plasma triacylglycerol levels by 26%, resulting from a marked reduction in VLDL1 triacylglycerol (0.62 vs 0.29 mmol/l, p < 0.001). Fenofibrate caused an increase in LDL size (Delta 0.80 nm, p < 0.001). HDL-C was similar between the groups. HDL2-C was decreased by fenofibrate (-27.5% at 5th year, p < 0.001) and HDL3-C increased (13.0% at 5th year, p < 0.001). Fenofibrate had no effect on apoA-I, whereas apoA-II increased. Thus, LpA-I decreased while LpAI-AII increased. Activities of cholesteryl ester transfer protein, phospholipids transfer protein and lecithin:cholesterylacyl transferase were unchanged by fenofibrate. High homocysteine levels were associated with a slight decrease in HDL-C and apoA-I.

CONCLUSIONS/INTERPRETATION

Fenofibrate markedly reduced large VLDL particles and produced a clear shift in HDL subspecies towards smaller particles. The HDL3-C increase in conjunction with unchanged apoA-I [corrected] levels is a dilemma with regard to cardiovascular disease.

Association of leisure time physical activity and abdominal obesity with fasting serum insulin and 2-h postchallenge plasma glucose levels

AIMS

We investigated the joint associations of leisure time physical activity and abdominal obesity with fasting insulin and 2-h glucose levels and with the risk of impaired glucose tolerance (IGT) and Type 2 diabetes (Type 2 DM).

METHODS

A cross-sectional population-based random sample of 1812 Finnish adults 45-74 years of age without a history of cardiovascular disease or diabetes. Relative energy expenditure during the previous 12 months (METh/week), assessed by a questionnaire, was used as a measure of leisure time physical activity. Waist-hip ratio (WHR) was used as a measure of abdominal obesity. IGT and Type 2 DM were assessed by a 2-h oral glucose tolerance test and were defined according to the World Health Organization guidelines.

RESULTS

While 2-h glucose and fasting insulin levels increased with increasing WHR (P < 0.001 and P < 0.001, respectively), both of them decreased with increasing physical activity (P = 0.015 and P < 0.001, respectively). The highest 2-h glucose and fasting insulin levels were found among individuals who had most abdominal obesity and were least physically active. Physically inactive individuals had a higher prevalence of IGT and Type 2 DM in all WHR tertiles than physically active persons.

CONCLUSIONS

Higher levels of leisure time physical activity are associated with lower 2-h glucose and fasting insulin levels and a reduced risk of having IGT and Type 2 DM, independent of the level of abdominal obesity.

Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population

OBJECTIVE

High sodium intake increases the risk of cardiovascular diseases and may also be associated with higher rates of stomach cancer, asthma disorders and infections. In Finland, cross-sectional population surveys to monitor cardiovascular risk factors have been carried out since the 1970s. The main aim of this paper is to present trends in urinary sodium and potassium excretion from 1979 to 2002.

DESIGN

Cross-sectional population surveys on cardiovascular risk factors.

SETTING

Surveys were carried out in Finland in 1979, 1982, 1987 and 2002 in four geographical areas: North Karelia, the Kuopio area, Southwestern Finland and the Helsinki area.

SUBJECTS

For each survey a random sample stratified by age and sex was drawn from the population register. In this analysis, participants of urine collection subsamples aged 25-64 years (n = 4648) were included.

INTERVENTIONS

A 24-h urinary collection was carried out in subsamples (n = 2218-2487) in connection with population risk factor surveys. Urinary sodium and potassium concentrations were analyzed in the same laboratory throughout, using a flame photometer in 1979, 1982 and 1987 and an ion-selective electrode in 2002.

RESULTS

Between 1979 and 2002 urinary sodium excretion in Finland decreased from over 220 to less than 170 mmol/day among men and from nearly 180 to less than 130 mmol/day among women. Although potassium excretion decreased somewhat as well, the decrease in sodium-potassium molar ratio was also significant.

CONCLUSIONS

The 24-h urinary sodium excretion in Finland has decreased significantly during the last 20 years. However, excretion levels are still considerably higher than recommendations. A further decrease in sodium intake remains a goal for the Finnish food industry and consumers.

SPONSORSHIP

All surveys were funded by the National Public Health Institute in Finland.

Safety aspects and cholesterol-lowering efficacy of low fat dairy products containing plant sterols

OBJECTIVE

The aim of this study was to investigate whether a plant sterol mixture would reduce serum cholesterol when added to low fat dairy products in subjects with hypercholesterolaemia, and to examine the effects of the mixture on the serum plant sterol and fat-soluble vitamin levels.

DESIGN

A parallel, double-blind study.

SETTING

The study was performed in three different locations in Finland.

SUBJECTS

In total, 164 mildly or moderately hypercholesterolaemic subjects participated in the study.

METHODS

The subjects were randomly divided into two groups: a plant sterol group and a control group. The subjects consumed the products for 6 weeks after a 3-week run-in period. The targeted plant sterol intake was 2 g/day in the sterol group.

RESULTS

During the treatment period, there was a 6.5% reduction in serum total cholesterol in the sterol group while no change was observed in the control group (P<0.0005). Serum low-density lipoprotein (LDL) cholesterol was reduced by 10.4% in the sterol group and by 0.6% in the control group (P<0.00005). There was no change during the trial in serum high-density lipoprotein (HDL) cholesterol or triacylglycerol concentrations. The HDL/LDL cholesterol ratio increased by 16.1% in the sterol group and by 4.3% in the control group (P=0.0001). Serum plant sterol levels increased significantly (P=0.0001) in the sterol group. None of the fat-soluble vitamin levels decreased significantly when changes in serum total cholesterol were taken into account. The hypocholesterolaemic effect of sterol administration was not influenced by apolipoprotein E phenotype.

CONCLUSIONS

Yoghurt, low-fat hard cheese and low-fat fresh cheese enriched with a plant sterol mixture reduced serum cholesterol in hypercholesterolaemic subjects and no adverse effects were noted in the dietary control of hypercholesterolaemia.

Effects of coffee consumption on glucose tolerance, serum glucose and insulin levels--a cross-sectional analysis

OBJECTIVE

Coffee has several metabolic effects that could reduce the risk of type 2 diabetes. Our objective was to examine the effects of coffee consumption on glucose tolerance, glucose and insulin levels.

RESEARCH DESIGN AND METHODS

A subsample of subjects aged 45 to 64 years in 1987 and in 1992 from the population-based FINRISK study (12,287 individuals) was invited to receive the standard oral glucose tolerance test at baseline. Plasma samples were taken after an overnight fast, and a two-hour oral glucose tolerance test was administered. Fasting and two-hour plasma glucose and insulin were measured in 2434 subjects with data on coffee use and potential confounders.

RESULTS

After adjustment for potential confounding factors (age, body mass index, systolic blood pressure, occupational, commuting and leisure time physical activity, alcohol and tea drinking, smoking), coffee consumption was significantly and inversely associated with fasting glucose, two-hour plasma glucose, and fasting insulin in both men and women. Coffee consumption was significantly and inversely associated with impaired fasting glucose, impaired glucose regulation, and hyperinsulinemia among both men and women and with isolated impaired glucose tolerance among women.

CONCLUSIONS

In this cross-sectional analysis, coffee showed positive effects on several glycemia markers.

Lipoprotein parameters in relation to other risk factors of atherosclerosis in adults and newborns: Tallinn Young Family Study

A cohort of young families from Tallinn was studied for coronary risk factors. In sera from 239 adults and cord blood from 138 of their newborns, TC, HDL-C, LDL-C, TG, Lp(a) and apo-B levels were determined, and body mass index (BMI) and lifestyle factors were registered. In newborns, characteristics of maturity were assessed by Dubowitz and Apgar scores after birth. The aim of the study was to investigate the risk factors for atherosclerosis in young families and to reveal the main determinants of atherogenic lipoprotein parameters in adults and newborns. Using the criteria of the International Lipid Information Bureau, it was found that 24.4% of the men and 9.8% of the women were hypercholesterolemic, 31.5% of the men and 9.6% of the women had low HDL-C, TG levels were elevated accordingly in 5.3% and 1.2% of subjects. The independent determinants of TG level in males were BMI and age, and for LDL-C and apo-B levels--BMI, age and nationality. Female neonates had higher TC, HDL-C and apo-B levels than male neonates, the differences seeming to be associated with the different physiological requirements of male and female fetuses. Newborns' HDL-C levels were correlated positively with their TCs (r=0.72; p<0.001), LDL-C (r=0.47; p<0.001) and apo B (r=0.23; p<0.05). A negative linear correlation was found between neonates' TC levels and the Dubowitz maturity score (r=-0.22; p=0.038). Serum Lp(a) levels did not differ significantly between males and females, either in adults or in newborns. The independent determinants of neonates' serum Lp(a) concentrations were parents' serum levels of Lp(a) and nationality.

Prevalence of diabetes and impaired glucose regulation in 45- to 64-year-old individuals in three areas of Finland

AIMS

To determine the prevalence of diabetes mellitus (DM), impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) and possible regional differences in Finnish adults aged between 45 and 64 years.

METHODS

A population sample of 2642 subjects aged between 45 and 64 years living in three geographical areas in Finland was invited to an oral glucose tolerance test.

RESULTS

The glucose tolerance status of 2087 subjects (79.0%) was determined. The age-standardized prevalence of DM in men and women was 10.2% and 7.4%, respectively (P = 0.020 for difference between sexes), and that of IGT 10.5% in men and 9.2% in women. IFG in men was more than twice as common as in women (13.5% vs. 5.0%, respectively, P < 0.001). Abnormal glucose tolerance was most common in southern compared with southwestern and eastern Finland. Of all diabetic subjects, 44% were previously undiagnosed.

CONCLUSIONS

The age-standardized prevalence of DM in 45- to 64-year-old Finns was within the range defined in previous studies on Europid populations. DM and IFG were more common in men than in women. Regional differences in the prevalence of abnormal glucose regulation suggest differences in lifestyle within an ethnically homogenous population.

Effect of a diet based on low-fat foods enriched with nonesterified plant sterols and mineral nutrients on serum cholesterol

Plant sterols have been incorporated into nutritional fats to achieve cholesterol lowering, but studies using enrichment of low-fat foods with plant sterols have not been reported. Our study was aimed at determining the effect of dietary intake of low-fat foods containing natural nonesterified plant sterols together with recommended doses of calcium, magnesium, and potassium on serum cholesterol and low-density lipoprotein (LDL) cholesterol-lowering in persons with mild to moderate hypercholesterolemia. This was a randomized, double-blind, placebo-controlled feeding trial lasting 15 weeks and performed in 2 university hospital centers. Seventy-eight subjects aged 25 to 75 years with serum cholesterol concentrations varying between 6 mmol/L (232 mg/dl) and 8 mmol/L (310 mg/dl) were randomly allocated to active treatment consisting of intake of bread, meat products, and jam enriched with 1.25 to 5.0 g/day of plant sterols and the slightly elevated concentrations of mineral nutrients, or the corresponding placebo food items. Serum lipid, high-density lipoprotein cholesterol and calculated LDL cholesterol concentrations were determined. Seventy-one persons completed the trial. Reduction in serum total cholesterol was 8% in the active treatment group and 3% in the placebo group (p = 0.0071) and that of LDL cholesterol was 13% in the active treatment group and 5% in the placebo group (p = 0.0070). In conclusion, natural nonesterified plant sterols contained in low-fat food items and ingested in moderate doses reduced serum total and LDL cholesterol concentrations to the same extent as reported previously for esterified plant sterol derivatives added to nutritional fats. The presence of mineral nutrients in doses recommended for blood pressure-lowering did not interfere with the cholesterol-lowering efficacy of the sterols, providing a promising approach to dietary prevention of cardiovascular diseases.

Association of carbohydrate-deficient transferrin (CDT) and gamma-glutamyl-transferase (GGT) with serum lipid profile in the Finnish population

BACKGROUND

Moderate consumption of alcohol may reduce mortality from vascular diseases. The beneficial effects of alcohol may partly be mediated by its effects on lipoprotein metabolism. We studied the connection between alcohol consumption and the serum lipid profile from a well-documented national health program study.

METHODS AND RESULTS

Carbohydrate-deficient transferrin (CDT) and gamma-glutamyl-transferase (GGT) were used as biochemical markers for alcohol consumption. The laboratory analyses were carried out on 5675 subjects (3097 males and 2578 females). The subjects were divided into quartiles on the basis of CDT or GGT value. The highest CDT quartile and the lowest GGT quartile seemed to be associated with a favorable lipid profile and the lowest CDT quartile and the highest GGT quartile were associated with an unfavorable lipid profile. Serum high density lipoprotein (HDL) cholesterol values were significantly higher and triglycerides lower with increasing serum CDT concentrations for both men and women. Increasing serum GGT was associated with higher serum total cholesterol and higher triglycerides in both men and women and lower HDL cholesterol in men.

CONCLUSIONS

CDT and GGT seem to detect different populations of subjects in regard to lipid metabolism. These observations may lead to a better understanding of the effects of alcohol consumption on lipids as well as mechanisms behind favorable and detrimental effects of alcohol on vascular diseases.

CONDENSED ABSTRACT

Carbohydrate-deficient transferrin (CDT) and gamma-glutamyl-transferase (GGT) were used as biochemical markers for alcohol consumption. A total of 3097 males and 2578 females were divided into quartiles on the basis of their CDT or GGT values. The highest CDT quartiles had higher HDL and lower triglycerides, whereas the highest GGT quartiles appeared to be associated with higher total cholesterol and triglycerides in both genders and lower HDL in men. CDT and GGT seem to detect different populations of subjects in regard to lipid metabolism. These observations may have important clinical and public health implications.

Dose response of laboratory markers to alcohol consumption in a general population

The dose response to alcohol use of carbohydrate-deficient transferrin (CDT), gamma-glutamyltransferase (GGT), and their combination (gamma-CDT) was studied in an age- and gender-stratified, random sample from Finland in 1997. A linear association with a threshold between alcohol consumption and the three markers was observed. Body mass index was negatively associated with CDT and positively with GGT Age was positively associated with GGT and gamma-CDT In conclusion, CDT appears to be an early phase marker of alcohol consumption. The combined marker, gamma-CDT, was less associated with factors such as body mass index but more strongly correlated with alcohol consumption than were the two markers separately.

The Finnish Diabetes Prevention Study

The aim of the Finnish Diabetes Prevention Study is to assess the efficacy of an intensive diet-exercise programme in preventing or delaying type 2 diabetes in individuals with impaired glucose tolerance (IGT) and to evaluate the effect of the programme on the risk factors of atherosclerotic vascular diseases and the incidence of cardiovascular events. In this ongoing study, a total of 523 overweight subjects with IGT based on two oral glucose tolerance tests were randomized to either an intervention group or a control group. The main measure in the intervention group is individual dietary advice aimed at reducing weight and intake of saturated fat and increasing intake of dietary fibre. The intervention subjects are individually guided to increase their level of physical activity. The control group receives general information about the benefits of weight reduction, physical activity and healthy diet in the prevention of diabetes. A pilot study began in 1993, and recruitment ended in 1998. By the end of April 1999 there were 65 new cases of diabetes, 34 drop-outs and one death. The weight reduction was greater (-4.6 kg) at 1 year in the intervention group (n = 152) than in the control group (n = 143, -0.9 kg, P < 0.0001), and this difference was sustained in the second year of follow-up. At 1 year 43.4% and at 2 years 41.8% of the intervention subjects had achieved a weight reduction of at least 5 kg, while the corresponding figures for the control subjects were 14.0 and 12.0% (P < 0.001 between the groups). At 1 year the intervention group showed significantly greater reductions in 2 h glucose, fasting and 2 h insulin, systolic and diastolic blood pressure, and serum triglycerides. Most of the beneficial changes in cardiovascular risk factors were sustained for 2 years. These interim results of the ongoing Finnish Diabetes Prevention Study demonstrate the efficacy and feasibility of the lifestyle intervention programme.

Laboratory standardization of a large international clinical trial: the DAIS experience. DAIS Project Group. Diabetes Atherosclerosis Intervention Study

OBJECTIVE

To implement a quality control program for the standardization and harmonization of lipid and lipoprotein analyses as performed at two core laboratories (St. Paul's Hospital, UBC [Vancouver], and NPHI [Helsinki]) for the Diabetes Atherosclerosis Intervention Study (DAIS).

DESIGN AND METHODS

A DAISSOFT computer program was designed to minimize the occurrence of data and sample management errors during the course of the study. Fresh human serum was used for the provision of an accuracy based external quality control program that monitored the analytical performance of lipid testing at these two laboratories. A separate program was designed for monitoring hemoglobin A1c (HbA1c). At the outset of the study, allowable total error goals were established for each analyte. Ongoing performance was monitored using bimonthly blinded challenges of fresh human serum. The two EQA programs routinely monitored the analysis of total cholesterol, calculated LDL-cholesterol, HDL-cholesterol, net triglycerides, apoprotein A-1, apoprotein B, and HbA1c.

RESULTS

The EQA precision and accuracy data for the measurement of total cholesterol at the two core laboratories over the last 5 years indicated both laboratories operated with good precision, approximately 1% CV over the time period. The accuracy at both laboratories was similar initially. Part way through the study, the accuracy of the cholesterol method at NHPI tended to drift upward with an operating positive bias (+3%) relative to the Abell Kendall reference method. Triglyceride measurements were the most problematic for the study. By EQA cycle 8, the accuracy of the method at UBC had stabilized and was meeting the accuracy goals of the study. NPHI's method was negatively biased relative to the accuracy base of the DAIS study. In spite of recalibrating their method, NPHI found it difficult to maintain consistent accuracy for the measurement of triglycerides during the study. Both laboratories operated their HDL methods with excellent precision. Accuracy at NHPI was well maintained over the course of the study whereas the accuracy of HDL measurements at UBC was more problematic. There was an inconsistent variation in the accuracy of apoprotein A-1 measurements at both laboratories. In most cases, the bias would be corrected by the time of the next EQA challenge. In the case of apo B, one laboratory was standardized to the CDC while the other laboratory was standardized to IFCC/WHO. The discrepancy between these two accuracy bases was >20%. Recalibration to a common accuracy base rectified the problem. Only minor problems were encountered with the precision and accuracy of the DIAMAT assay for hemoglobin A-1c. The two DAIS core laboratories consistently operated within the 9% total error goals of the study for HbA1c.

CONCLUSIONS

Through the use of this program, the two DAIS core laboratories were able to maintain their lipid analyses within the limits of allowable total error that had been established for the study.

Cardiovascular risk factor changes in Finland, 1972-1997

BACKGROUND

The cardiovascular risk factor levels of the population have been assessed in Finland since 1972. In the beginning the surveys were done to evaluate the North Karelia Project, which was a community-based preventive programme. A national cardiovascular disease (CVD) prevention strategy was developed and implemented during the late 1970s. Subsequently, a national cardiovascular risk factors monitoring system was developed to assess the effectiveness of the national strategy.

METHODS

Cross-sectional population samples were studied in 1972 and 1977 in North Karelia and Kuopio provinces in eastern Finland. An area in southwestern Finland was included in 1982, followed by the Helsinki metropolitan area in 1992 and Oulu province in northern Finland in 1997. A total of 19 761 men and 20 761 women aged 30-59 participated in the six surveys (1972, 1977, 1982, 1987, 1992, 1997).

RESULTS

The serum cholesterol levels of both genders have continuously declined. Systolic blood pressure levels have declined since 1972, but no further decline in diastolic blood pressure was found in 1997. Smoking prevalence among men continued to decline mainly due to an increase in the percentage of never-smokers. For the first time the increase in smoking prevalence among women levelled off and started to decline, mainly because the number of female quitters had increased.

CONCLUSIONS

These data suggest that the cardiovascular health programme in Finland has succeeded in decreasing the general risk factor level of the population.

Trends in lipid levels and hypercholesterolemia in hypertensive and normotensive finnish adults from 1982 to 1997

OBJECTIVES

To assess the trends in lipid levels and awareness of hypercholesterolemia in hypertensive and normotensive population in Finland from 1982 to 97.

DESIGN

Four independent cross-sectional population surveys conducted in 1982, 1987, 1992 and 1997.

SETTING

The provinces of North Karelia and Kuopio in eastern Finland and the region of Turku-Loimaa in south-western Finland.

SUBJECTS

Men and women aged 25-64 years, selected randomly from the national population register. The subjects were classified to four groups according to their blood pressure level and treatment status: normotensive, unaware hypertensive, aware but not treated hypertensive and treated hypertensive. The total number of participants was 24 083.

MAIN OUTCOME MEASURES

We assessed the mean serum total cholesterol and HDL cholesterol concentrations, the prevalence of hypercholesterolemia (total cholesterol >/=6.5 mmol L-1 or the use of lipid-lowering drugs), the prevalence of a high ratio of total cholesterol to HDL cholesterol (ratio >/=5) and the awareness of hypercholesterolemia amongst the four study groups.

RESULTS

Mean total cholesterol, the prevalence of hypercholesterolemia and the prevalence of a high ratio of total to HDL cholesterol decreased, whereas the awareness of hypercholesterolemia increased significantly in all study groups. The decline in mean total cholesterol was largest in treated hypertensive subjects of both sexes (13% in men, 14% in women). Mean HDL cholesterol increased significantly in all study groups except in the unaware hypertensive men, but it remained significantly lower in treated hypertensive patients in both sexes compared with the other groups (P < 0.001).

CONCLUSIONS

The lipid profile of both the hypertensive and normotensive population has significantly improved in both the hypertensive and normotensive population in Finland from 1982-97. The introduction of newer antihypertensive drugs has not had any effect on the HDL cholesterol level amongst treated hypertensive patients at the population level.

Serum phospholipid transfer protein activity and genetic variation of the PLTP gene

The inverse relationship between serum levels of high density lipoproteins (HDL) and risk of coronary heart disease is well established. The phospholipid transfer protein (PLTP) promotes the transfer of phospholipids between lipoproteins and modulates HDL size and composition. It thus plays a central role in HDL metabolism. Serum PLTP activity was measured in 400 healthy Finnish individuals in order to determine normal PLTP serum values. PLTP activity increased with age (P<0.001), so that the PLTP activity was 3.81+/-0.84 micromol/ml per h (mean +/- S.D., n = 52) for men and 3.97+/-0.11 micromol/ml per h (n = 52) for women in the youngest age group (25-35 years), while it was 6.77+/-0.17 micromol/ml per h (n = 45) for men and 6.68+/-0.15 micromol/ml per h (n = 40) for women in the oldest age group (56-65 years). PLTP activity correlated significantly (P<0.001) with body mass index (r = 0.22), serum total cholesterol (r = 0.17), the ratio of HDL-cholesterol/total cholesterol (r = -0.20), triglycerides (r = 0.20), apo A-II (r = 0.20), and gamma glutamyl transferase (r = 0.22) values. Serum PLTP activity correlated negatively (r = -0.20, P<0.001) with levels of apolipoprotein A-I in HDL particles that contained only apo A-I [Lp(A-I) particles]. The allelic frequencies of six intragenic polymorphisms, -79G/T, -56G/A, -37T/C, -31A/G, Phe2Leu, Arg121Trp, and two neutral polymorphisms, located in the immediate vicinity of the PLTP gene were determined. There were no significant associations between these polymorphisms and serum PLTP activity.

Prevention of Type II diabetes in subjects with impaired glucose tolerance: the Diabetes Prevention Study (DPS) in Finland. Study design and 1-year interim report on the feasibility of the lifestyle intervention programme

AIMS/HYPOTHESIS; The aim of the Diabetes Prevention Study is to assess the efficacy of an intensive diet-exercise programme in preventing or delaying Type II (non-insulin-dependent) diabetes mellitus in subjects with impaired glucose tolerance, to evaluate the effects of the intervention programme on cardiovascular risk factors and to assess the determinants for the progression to diabetes in persons with impaired glucose tolerance.

METHODS

A total of 523 overweight subjects with impaired glucose tolerance ascertained by two oral glucose tolerance tests were randomised to either a control or intervention group. The control subjects received general information at the start of the trial about the lifestyle changes necessary to prevent diabetes and about annual follow-up visits. The intervention subjects had seven sessions with a nutritionist during the first year and a visit every 3 months thereafter aimed at reducing weight, the intake of saturated fat and increasing the intake of dietary fibre. Intervention subjects were also guided individually to increase their physical activity.

RESULTS

During the first year, weight loss in the first 212 study subjects was 4.7 +/- 5.5 vs 0.9 +/- 4.1 kg in the intervention and control group, respectively (p < 0.001). The plasma glucose concentrations (fasting: 5.9 +/- 0.7 vs 6.4 +/- 0.8 mmol/l, p < 0.001; and 2-h 7.8 +/- 1.8 vs 8.5 +/- 2.3 mmol/l, p < 0.05) were significantly lower in the intervention group after the first year of intervention. Favourable changes were also found in blood pressure, serum lipids and anthropometric indices in the intervention group.

CONCLUSION/INTERPRETATION

The interim results show the efficacy and feasibility of the lifestyle intervention programme.

Interrelationships between low density lipoprotein receptor defect, serum fatty acid composition, and serum cholesterol concentration

It is known that, in the general human population, serum fatty acid composition is correlated with serum triacylglycerol and cholesterol concentrations. The goal of the present study was to analyze whether the same is true of individuals who have a low density lipoprotein receptor (LDL-R) defect. Concentrations of 16 different fatty acids, cholesterol, triacylglycerol, and major lipoproteins in serum were determined in eight individuals who had (FH-North Karelia), the most common LDL-R defect in Finland, which causes familial hypercholesterolemia, and in their 30 relatives belonging to a single large pedigree as controls. The average number of double bonds (i.e., degree of desaturation) in serum fatty acids correlated negatively with the concentrations of serum total cholesterol (r = 0.27, P < 0.05) and total triacylglycerol (r = -0.71, P < 0.001) and positively with the number of fish meals per week (r = 0.50, P < 0.01), which was analyzed in all pedigree members jointly. These effects were similar in individuals having LDL-R defect, in which group the correlation coefficients were -0.31 (P = NS), -0.99 (P < 0.001), and 0.79 (P = NS) for serum total cholesterol, triacylglycerol, and weekly fish meals, respectively. Thus, LDL-R defect does not impair the correlation between serum fatty acid composition and serum triacylglycerol concentration. This result is in agreement with dietary studies that have shown that familial hypercholesterolemia patients respond very favorably to dietary therapy.

Lipoprotein(a), apolipoprotein A-I and B serum levels in young families from Tallinn, Estonia. Relationships with other cardiovascular risk factors and nationality

Serum lipid, lipoprotein(a) (Lp(a)), apolipoprotein (apo) A-I and B concentrations were studied in young families of Tallinn: 157 husbands, 81 wives and 149 newborns participated in the study; 48% of subjects were Estonians, 39% Russians and 13% other nationalities. As previous studies among middle-aged men and school children of Estonia revealed clear national differences in serum lipoprotein profiles, our special interest was to study lipoprotein parameters in relation to ethnic origin. Body mass index (BMI), blood pressure (BP) and smoking habits were determined. In newborns, maturity by physical and neurological criteria and Apgar score after birth were assessed. At the age of 18-30 years, Estonian men had significantly higher serum total cholesterol, LDL cholesterol, triglyceride and Lp(a) levels than did Russian men. Estonian newborns had higher serum triglyceride concentration than Russian ones. Among women no national differences were recorded in the measured parameters. Lp(a) levels were not statistically correlated with age, BMI, BP or current smoking. Negative associations were revealed between Lp(a) and serum level of apo A-I (in men) or triglycerides (in newborns). Lp(a) concentrations correlated positively with LDL cholesterol (in women) and apo B (in newborns). Lp(a) levels of newborns were not associated with birthweight or health status, but correlated strongly with the sum of parental and fathers' Lp(a) concentrations, demonstrating that a genetic factor(s) is involved in the values of plasma Lp(a) levels.

Serum cholesterol distribution and coronary heart disease risk: observations and predictions among middle-aged population in eastern Finland

BACKGROUND

The purpose of the present study was to assess the implications of cholesterol distribution and its change on coronary heart disease (CHD) mortality and disease prevention at a population level.

METHODS AND RESULTS

In five independent risk factor surveys (1972, 1977, 1982, 1987, and 1992) in eastern Finland, serum cholesterol was measured in 27721 randomly selected men and women aged 30 to 59 years. The association between cholesterol level and CHD risk and the prediction of the effect of different prevention strategies was estimated by use of logistic regression models. The entire cholesterol distribution of the population shifted markedly toward lower levels between 1972 and 1992. The proportion of subjects with a very high cholesterol level (> or =8.0 mmol/L), also decreased markedly, from 16% to 3%. The risk of CHD death among subjects with cholesterol > or =8.0 mmol/L was approximately 5-fold that of those individuals having cholesterol <5.0 mmol/L. Nevertheless, because CHD risk increases continuously as serum cholesterol increases, and because the number of people having only slightly or moderately increased serum cholesterol was large, most CHD deaths occurred among them. A 10% reduction in cholesterol levels in the entire population would subsequently reduce CHD mortality by 20%, as much as an effective treatment as a 25% decrease in serum cholesterol among all subjects with cholesterol >6.5 mmol/L and four times more than similar treatment of all subjects with cholesterol > or =8.0 mmol/L.

CONCLUSIONS

The community-based population strategy in cardiovascular disease prevention was effective in decreasing cholesterol levels among the entire population, including the subjects with the highest cholesterol values. The balanced application of both high-risk and population strategies is needed for the effective prevention of CHD.

The effect of alpha-tocopherol and beta-carotene supplementation on COPD symptoms

The effects of alpha-tocopherol (50 mg/d) and beta-carotene (20 mg/d) supplementation on symptoms of chronic obstructive pulmonary disease were studied among the 29,133 participants of the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study undertaken to investigate the effects of these two substances in the prevention of lung and other cancers. During the follow-up the supplementations did not affect the recurrence or incidence of chronic cough, phlegm, or dyspnea. The prevalence of chronic bronchitis and dyspnea at baseline was lower among those with high dietary intake of beta-carotene (OR = 0.78 and 0.67, respectively) or vitamin E (OR = 0.87 and 0.77) and high serum beta-carotene (OR = 0.59 and 0.62) and alpha-tocopherol (OR = 0.76 and 0.82). High intake and serum levels of retinol were associated with low prevalence of dyspnea (OR = 0.84 and 0.80, respectively) but not with chronic bronchitis. The results indicate no benefit from supplementation with alpha-tocopherol or beta-carotene on the symptoms of chronic obstructive pulmonary disorders but support the beneficial effect of dietary intake of fruits and vegetables rich in these compounds.

Comparison of a new immunoturbidometric assay of human serum lipoprotein (a) to the ELISA and the IRMA methods

In the present work we have tested a new immunoturbidometric (IT) lipoprotein(a) (Lp(a)) assay and compared it with two other Lp(a) assay systems (IRMA and ELISA) commonly used in clinical chemistry laboratories. In addition, we have examined the effects of long-term storage and plasminogen on the results of Lp(a). Intra-assay and inter-assay coefficients of variation of the IT method were from 1.6 to 5.5% and from 2.8 to 10.7% depending on the concentration of Lp(a). The correlations between methods were 0.957 (IRMA vs. IT), 0.969 (IRMA vs. ELISA) and 0.956 (IT vs. ELISA) and the regression curves were IRMA = 1.07*IT + 11, IRMA = 1.84*ELISA + 2 and IT = 1.62*ELISA + 17, respectively. Storage of the samples for 5 years at -70 degrees C did not affect serum Lp(a) levels. There was a slight increasing effect of high concentrations of plasminogen on the Lp(a) results, but on physiological serum levels of plasminogen the effect was not significant. We conclude that the IT method provides a simple way to screen serum Lp(a) levels.

New method to assess dilution of secretions for immunological and microbiological assays

Accurate quantitation of pathogens and antibody concentrations in secretions has been difficult because of unpredictable dilution of secretion with th diluent at the time of sample collection. We added an inert substance, lithium chloride (LiCl), to the sample diluent and measured its concentration with an atomic absorption spectrometer before and after the specimen was added. LiCl, at a concentration of 2 mmol of Li per liter, has no negative effect on the survival of common respiratory pathogens or on the results of immunoassays. The method is applicable to any sample collecting in which dilution of the specimen is necessary.