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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

FUNDING

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

Subjective Well-Being Is Associated with Food Behavior and Demographic Factors in Chronically Ill Older Japanese People Living Alone

OBJECTIVES

This study aimed to examine the relationships among subjective well-being, food and health behaviors, socioeconomic factors, and geography in chronically ill older Japanese adults living alone.

DESIGN

The design was a cross-sectional, multilevel survey. A questionnaire was distributed by post and self-completed by participants.

SETTING

The sample was drawn from seven towns and cities across Japan.

PARTICIPANTS

A geographic information system was used to select a representative sample of older people living alone based on their proximity to a supermarket. Study recruitment was conducted with municipal assistance.

MEASUREMENTS

To assess subjective well-being and food and health behaviors of respondents with disease, a logistic regression analysis was performed using stepwise variable analyses, adjusted for respondent age, socioeconomic status, and proximity to a supermarket. The dependent variable was good or poor subjective well-being.

RESULTS

In total, 2,165 older people (744 men, 1,421 women) completed the questionnaire (63.5% response rate). Data from 737 men and 1,414 women were used in this study. Among people with a chronic disease, individuals with good subjective well-being had significantly higher rates than those with poor subjective well-being for satisfaction with meal quality and chewing ability, food diversity, food intake frequency, perception of shopping ease, having someone to help with food shopping, eating home-produced vegetables, preparing breakfast themselves, eating with other people, and high alcohol consumption. A stepwise logistic analysis showed that the factors strongly related to poor subjective well-being were shopping difficulty (men: odds ratio [OR] = 3.19, 95% confidence interval [CI], 1.94-5.23; P < 0.0001; women: OR = 2.20, 95% CI, 1.54-3.14; P < 0.0001), not having someone to help with food shopping (women: OR = 1.41, 95% CI, 1.01-1.97; P = 0.043), not preparing breakfast (women: OR = 2.36, 95% CI, 1.40-3.98; P = 0.001), and eating together less often (women: OR = 1.99, 95% CI, 1.32-3.00; P = 0.002).

CONCLUSION

Subjective well-being of people with chronic diseases is associated with food intake and food behavior. The factors that affect poor subjective well-being in chronically ill older Japanese people living alone include food accessibility and social communication.

The association between health-related quality of life/dietary satisfaction and perceived food environment among Japanese individuals with spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To examine the association between health-related quality of life (HRQOL)/dietary satisfaction and perceived food environment in community-dwelling individuals with spinal cord injury (SCI).

SETTING

Members of the Spinal Injuries Japan organization.

METHODS

Subjects were 2007 Japanese individuals with SCI. A questionnaire conducted in 2015 included items addressing sociodemographic characteristics, HRQOL, dietary satisfaction and eight perceived food environment items. Responses from 506 individuals were analyzed (valid response rate=25%). Dependent variables were the physical and mental summary scores of the HRQOL and dietary satisfaction. The independent variable was the perceived food environment. We used a univariate analysis (in Model 1) and a multivariate analysis (in Models 2 and 3) as part of a binominal logistic regression analysis. In Model 3, we divided and analyzed the perceived food environment variable into 'access to food' and 'access to information'.

RESULTS

Both physical and mental summary scores were related to 'dietary information acquisition in the community'. Dietary satisfaction was related to 'balanced meals in the household', 'food and health information available from family' and 'right health and dietary information acquisition from the media'.

CONCLUSION

HRQOL and dietary satisfaction were differentially associated with perceived food environment factors in community-dwelling individuals with SCI. HRQOL was positively related to dietary information of perceived food environment in the community. Dietary satisfaction was positively related to perceived food environment in the household.

Association between Satisfaction with State of Health and Meals, Physical Condition and Food Diversity, Health Behavior, and Perceptions of Shopping Difficulty among Older People Living Alone in Japan

OBJECTIVE

This study aimed to examine perceptions of shopping difficulty, and the relationships with satisfaction with state of health and meals, physical condition, food diversity and health behavior in older people living alone in Japan.

DESIGN

A cross-sectional, multilevel survey was designed. The questionnaire was distributed by mail and self-completed by participants.

SETTING

The sample was drawn from seven towns and cities across Japan.

PARTICIPANTS

A geographic information system was used to select the sample of older people living alone, by proximity to a supermarket. In total, 2,346 older people (827 men and 1,519 women) completed the questionnaire.

MEASUREMENTS

The dependent variable was whether shopping was easy or difficult. A logistic regression analysis was performed, adjusting for age, socioeconomic status and proximity of residence to a supermarket using stepwise variable analyses.

RESULTS

The response rate was 67.8%. Overall, 14.5% of men and 21.7% of women considered shopping difficult. The stepwise logistic analysis showed that the factors most strongly related to shopping difficulty were a subjective feeling of poor health (men: OR = 3.01, women: OR = 2.16) and lack of satisfaction with meals (men: OR = 2.82, women: OR = 3.69). Other related physical condition and dietary factors were requiring nursing care (men: OR = 3.69, women: OR = 1.54), a high level of frailty, measured using the frailty index score (women: OR = 0.36) and low food diversity score (men: OR = 1.84, women: OR = 1.36).

CONCLUSION

The study found that older people's assessment of their shopping difficulty was related to satisfaction aspects, including a subjective feeling of poor health, and lack of satisfaction with meals, as well as physical condition. These have a greater influence on shopping difficulty than income in both sexes, and proximity to a supermarket in women.

"Eating Together" Is Associated with Food Behaviors and Demographic Factors of Older Japanese People Who Live Alone

OBJECTIVE

This study aimed to examine the relationships between eating together and subjective health, frailty, food behaviors, food accessibility, food production, meal preparation, alcohol intake, socioeconomic factors and geography among older Japanese people who live alone.

DESIGN

A cross-sectional, multilevel survey was designed. The questionnaire was distributed by post and self-completed by participants.

SETTING

The sample was drawn from seven towns and cities across Japan.

PARTICIPANTS

A geographic information system was used to select a representative sample of older people who lived alone based on their proximity to a supermarket. Recruitment for the study was conducted with municipal assistance.

MEASUREMENTS

A logistic regression analysis was performed that adjusted for the respondent's age, socioeconomic status and proximity to a supermarket using stepwise variable analyses. The dependent variable was whether the respondent ate together more or less than once a month.

RESULTS

In total, 2,196 older people (752 men and 1,444 women) completed the questionnaire (63.5% response rate). It was found that 47.1% of men and 23.9% of women ate together less than once a month. Those who ate together less than once a month had a significantly lower rate of subjective health, food diversity and food intake frequency than those who ate together more often. A stepwise logistic analysis showed that the factors most strongly related to eating together less than once a month were not having any food shopping assistance (men: OR = 3.06, women: OR = 2.71), not receiving any food from neighbors or relatives (men: OR = 1.74, women: OR = 1.82), daily alcohol intake (women: OR = 1.83), frailty (men: OR = 0.48) and income (men: OR = 2.16, women: OR = 1.32).

CONCLUSION

Eating together is associated with subjective health and food intake. Factors that affect how often older Japanese people who live alone eat together include food accessibility, daily alcohol intake, frailty and a low income.

Food Accessibility and Perceptions of Shopping Difficulty among Elderly People Living Alone in Japan

OBJECTIVES

This aim of this study was to describe the association between shopping difficulty and food accessibility for elderly people living alone in Japan.

DESIGN

A cross-sectoral, multilevel survey was designed to measure shopping difficulty from a food accessibility perspective. The questionnaire was distributed by mail.

SETTING

The sample was drawn from seven towns and cities across Japan.

PARTICIPANTS

A geographic information system was used to select the sample: it identified the proximity of elderly people living alone to a supermarket. In total, 2,028 elderly people (725 men and 1,303 women) responded to the questionnaire.

MEASUREMENTS

The binary dependent variables were shopping is easy/shopping is difficult. A logistic regression analysis adjusting for age and area of residence and using stepwise variable analyses was performed.

RESULTS

The response rate was 58.6%. Overall, 14.6% of elderly men and 21.7% of elderly women consider shopping difficult. The stepwise logistic analysis showed that the food accessibility factors strongly related to shopping difficulty are infrequent car use (women: OR = 6.97), walking difficulties (men: OR = 2.81, women: OR = 3.48), poor eyesight (men: OR = 2.26, women: OR = 1.75), not cooking lunch by oneself (men: OR = 1.63, women: OR = 1.72), not having anyone to help with food shopping (women: OR = 1.45) and living over 1 km away from a supermarket (men: OR = 2.30, women: OR = 2.97).

CONCLUSION

The study concludes that elderly people's assessment of shopping difficulty is related to their food accessibility. Important food accessibility aspects include car or motorbike ownership, walking continuously for 1 km, poor eyesight, and having cooking skills and having someone to help with shopping. These physical activity restrictions have a greater influence on shopping difficulty than do either income or proximity to a supermarket.

Perceived body size and desire for thinness of young Japanese women: a population-based survey

The present study describes findings in relation to perceived body size and 'desire for thinness' by age and residential areas ('metropolitan areas', 'large cities', 'small cities' and 'towns') among young Japanese women. Data on 1731 non-pregnant, non-lactating women aged 15-39 years from the 1998 National Nutrition Survey of Japan were used. Current body size was evaluated by BMI percentiles (lean, <5th; underweight, 5th or = BMI <25th; normal, 25th< or = BMI< 75th; overweight, 75th < or =BMI <95th; obese, > or =95th), calculated for 5-year age groups. Perceived body size was obtained by self-report. We defined 'overestimation' as non-overweight, non-obese women who perceived themselves as being 'overweight' or 'obese'. Desired body size was evaluated by applying the desired BMI to these cut-off points. Of all the women, 48.4% perceived themselves as being 'overweight' or 'obese', and 43.7% desired a 'lean' or 'underweight' body size. Adjusted for the current BMI, the OR for 'overestimation' calculated by a logistic regression model was significantly elevated in the 15-19-year age group (OR 2.79; 95% CI 1.76, 4.43), compared with the 25-29-year age group. The OR for 'desire for thinness' was significantly high in the 35-39-year age group (OR 2.74; 95% CI 1.93, 3.89) and the 15-19-year age group (OR 2.26; 95% CI 1.57, 3.24). Women living in metropolitan areas had higher OR for 'desire for thinness' (but not for 'overestimation') than did women in towns (OR 1.47; 95% CI 1.05, 2.07). The findings suggest the nature of excessive weight concerns of young women in Japan; thus efforts to control such health-risk behaviours at a national level are urgent.

Folate intakes and folate biomarker profiles of pregnant Japanese women in the first trimester

OBJECTIVE

To assess the status of dietary folate intake, serum and red blood cell (RBC) folate, and related nutritional biomarkers in healthy Japanese women in early pregnancy.

DESIGN

A cross-sectional, observational study.

SUBJECTS

Pregnant women in the first trimester, at 7-15 weeks gestation (n=70), who were not consuming any folate supplements or folate fortified foods.

METHODS

Three-day dietary records were obtained from each subject to assess dietary folate intake. Blood samples were collected for measurement of biomarkers. Biomarkers and nutrient intake were analyzed in two groups defined by their serum folate concentrations: the low folate group (serum folate < 9 ng/ml) and the high folate group (serum folate > or = 9 ng/ml).

RESULT

Mean serum and RBC folate concentrations in all subjects were 10.3 and 519 ng/ml, respectively. These levels were remarkably higher than the reported values from many other countries despite our subjects receiving no folic acids supplements. However, mean folate intake by our subjects from natural foods was 289 microg/day, which is thought to be low according to the Japanese dietary recommendation specified for pregnant women. The intake of spinach and fruits was significantly greater in the high folate group than in the low folate group.

CONCLUSION

Folate intake was thought to be adequate to maintain a desirable level of serum folate concentration in Japanese pregnant women in the first trimester, although the intake of folate from natural food was not high enough to meet the recommended daily intake.

Maternal weight gain ranges for optimal fetal growth in Japanese women

OBJECTIVE

To identify adequate weight gain ranges during pregnancy in Japanese women.

METHOD

Obstetric records from 2001 to 2002 for 46,659 term, singleton, vaginally delivered live births was used to estimate IUGR and macrosomia risk. Total maternal weight gain was grouped according to gestational age-specific percentile values of weight gain as follows: "very low" (under the 25th), "low" (25th to 49th), "moderate" (50th to 74th), "high" (75th to 89th), and "very high" (90th and over).

RESULTS

About 6% of infants were identified as having IUGR and 0.9% as macrosomia. IUGR risk was elevated with low weight gains. Macrosomia risk was related to high weight gains and previous spontaneous abortions.

CONCLUSION

Achieving weight gains between the 50th and 75th percentiles for gestational age was considered adequate for optimal fetal growth in Japanese pregnant women.

Twenty-year changes in the prevalence of overweight in Japanese adults: the National Nutrition Survey 1976-95

The aim of this study was to describe the 20-year changes in body mass index (BMI; kgm(-2)) and the prevalence of overweight in Japanese adults. Cross-sectional annual nationwide surveys (National Nutrition Survey, Japan) were carried out with a large probability sample of the Japanese population. Data sets of the 1976-95 surveys, comprising 91983 men and 120822 women (> or =20 years of age), were used. The analyses were carried out in age and gender groups, and by residential area according to the size of the municipality (metropolitan areas, cities and small towns). The mean BMI increaseed in men with an increment of +0.44 kg m(-2) 10 years(-1) and slightly decreased in women, by -0.09 kg m(-2) 10 years(-1), after adjustment for age. A decreasing trend of mean BMI was most significant in the female 20-29 years age-group (-0.38 kg m(-2) 10 years(-1)), in contrast to an increasing trend observed in elderly women (60-69 and 70+ years age-groups). The prevalence of preobese (BMI: 25-29.9kg m(-2)) and obese (BMI > or = 30 kg m(-2)) men increased from 14.5% and 0.8%, respectively, in the time-period 1976-80 to 20.5% and 2.01% during 1991-95. The increasing trend was most evident in the youngest age-group (20-29 years) and in those from small towns. The overall prevalence of preobese and obese women did not change during the 20-year study period. The prevalence in younger women decreased, this trend being more prominent in metropolitan areas. Although the prevalence of overweight (BMI > or =25 kg m(-2)) in Japanese men and elderly women has increased in the last 20 years, the mean BMI in younger women, especially those in metropolitan areas, has decreased. A population approach to control obesity and prevent obesity-associated diseases should be mainly focused on men and women older than 40 years of age.

Dissecting the contradictory findings of angiotensin converting enzyme genetic polymorphism with blood pressure and hypertension

The studies on the association of deletion/insertion (D/I) polymorphism of angiotensin converting enzyme (ACE) gene with blood pressure and hypertension reported contradictory results. We review the articles that considered blood pressure or hypertension as the main outcome measure to have an overview of the situation. There is heterogeneity of allele frequencies of ACE locus among ethnic groups. In descending order of D allele frequencies, ethnic groups are: Gulf Bedouin (0.657), Black (0.597), White (0.577), Chinese (0.400), Japanese (0.377), Bangladeshi (0.374) and Indian Sikh (0.373). Multiple studies were available for the Caucasians and Japanese with relatively large sample sizes. Three out of five studies in the Caucasians found association either in males or in females with blood pressure or hypertension. None of the three Japanese studies observed an association. So, ACE locus may be considered a marker for blood pressure or hypertension in the Caucasians but not in the Japanese. This racial difference is not surprising, because heterogenecity of ACE activity according to ACE genotypes has been reported among ethnic groups, and important differences in environmental factors persist. Studies in other populations were either small or sampling procedures were not adequately described. Given that the studies varied in designs, settings, sample size, and adjustment for confounding variables, adequately powered large-scale multicentre, multi-ethnic population-based studies using same method are required to resolve this contradiction.

A validation study on a method to estimate nutrient intake by family members through a household-based food-weighing survey

The aim of the present study is to investigate the validity of a new method to estimate the food intake of individual subjects by a household-based dietary survey. The new method is based on the combination of household-based food weighing and approximating the proportions by which family members shared each dish or food in the household, which has been one of the components of the National Nutrition Survey, Japan, since 1995. We analyzed two sets of data from 64 volunteers (female students taking a dietitian course and their mothers) in 32 households by the approximated proportion method (method A) and the individual-based food weighing method (B) as a reference measurement. Energy and macronutrient intake by individual subjects estimated by method A was highly correlated to the corresponding values by method B (Pearson's correlation coefficients: r=0.90-0.92). Average energy intake was likely to be underestimated by method A compared with method B, being lower by 94 kcal (6.2% of the reference value in method B), at least in the young and middle-aged female adults that were the subjects of this study. When intake of boiled rice was separately analyzed, underestimation of energy intake by method A was 44 kcal, which contributed to approximately 50% of the total magnitude of the underestimation. The procedure manual for the National Nutrition Survey requests the participants to individually weigh the amount of boiled rice taken by family members in the household. However, this procedure is not observed in many actual settings. Therefore, following this procedure would be an effective measure to improve the accuracy of the dietary data.

Cardiovascular risk factors: distribution and prevalence in a rural population of Bangladesh

BACKGROUND

Little is known about the cardiovascular risk factors in the Bangladeshi population. We examined 'classic' risk factors, including central obesity, in a rural population.

METHODS

Non-biochemical variables were examined in 238 men and 272 women aged 18 years or more (mean +/- standard deviation 38.1 +/- 10.7 years in men and 36.0 +/- 9.8 in women). Fasting blood glucose and total cholesterol concentrations were determined in a sub-sample of 106 men and 135 women.

RESULTS

Men and women had a similar body mass index (20.4 +/- 3.1 vs 20.8 +/- 3.4 kg/m2), waist circumference (72.8 +/- 7.6 vs 71.4 +/- 8.7 cm), systolic blood pressure (118.4 +/- 13.7 vs 119.5 +/- 17.7 mmHg), diastolic blood pressure (75.9 +/- 9.9 vs 74.6 +/- 11.5 mmHg), total cholesterol (155.7 +/- 36.0 vs 162.0 +/- 35.2 mg/dl) and blood glucose level (89.0 +/- 14.9 vs 86.2 +/- 9.6 mg/dl. After categorization of these variables, the prevalence of thinness (body mass index < 18.5; 30.0 vs 30.3%), obesity (body mass index > or = 30; 0.8 vs 1.1%), hypertension (systolic blood pressure > or = 140 and/or diastolic blood pressure > or = 90 or medication; 9.8 vs 15.6%), hypercholesterolemia (total cholesterol > or = 240; 2.8 vs 3.0%) and diabetes mellitus (blood glucose > or = 126; 2.9 vs 0.7%) remained similar between the sexes. However, central obesity (waist circumference > or = 94 cm in men and > or = 80 cm in women) was less frequent (2.9 vs 16.8%; P = 0.001) in men. Overall, tobacco consumption (57.1 vs 23.2%; P = 0.001) and smoking (50.3% vs 2.9%; P = 0.001) were more frequent in men, but chewing tobacco consumption was similar (16.3 vs 21.4%; P = 0.095).

CONCLUSIONS

Our sample size is small, and larger studies are necessary for a more accurate description of the risk factors.

Validity, reliability and acceptability of the Japanese version of the General Well-Being Schedule (GWBS)

The General Well-Being Schedule (GWBS) is a widely used, self-administered questionnaire to measure subjective well-being. It contains 18 items and was originally hypothesized to have six domains; however, the following studies suggest other factorial models. We devised the schedule's Japanese edition following the standard procedure and tested its psychometric properties considering Japanese cultural characteristics. Subjects were 1224 middle-aged participants undergoing health checkups in Adachi, Tokyo. The reliability of the original version was high: alpha coefficient, 0.90; test-retest Pearson's correlation coefficient, 0.81; and intra-class correlation coefficient, 0.85. Confirmatory factor analyses supported the structural validity of the 6-factor, the following 3-factor and 4-factor models (goodness of fit index: 0.932, 0.946 and 0.937, respectively). A new 3-factor model developed after the exclusion of item 11, which had no correlation with the other variables, was proved to have a higher fitness index (0.958) than the other models. This 17-item version showed adequate reliability (alpha coefficient, 0.91; test-retest Pearson's correlation coefficient, 0.81; and intra-class correlation coefficient, 0.85) and concurrent validity compared with the General Health Questionnaire, State-Trait Anxiety Inventory, Center for Epidemiologic Studies Depression Scale, Self-rating Depression Scale and Profile Of Mood State (correlation coefficients: -0.75 to -0.53). The median time required to complete the schedule was five minutes. Completing this instrument was easy for 80% of the subjects. These findings attest to the adequacy of the 17-item Japanese GWBS for the comprehensive assessment of individual inner state.

Angiotensin converting enzyme genetic polymorphism is not associated with hypertension in a cross-sectional sample of a Japanese population: the Shibata Study

BACKGROUND

The studies on the association of deletion/ insertion (D/I) polymorphism of angiotensin converting enzyme (ACE) gene with blood pressure and hypertension reported contradictory results. Because there was no population-based study in Japan, we examine the hypothesized association in a cross-sectional sample of a Japanese cohort.

METHODS AND RESULTS

The blood pressure of 464 men and 876 women aged 40-80 years was measured, and their DNA was analyzed for ACE D/I genotypes. The prevalence of the D allele was 38.7 and 39.2% in men and women, respectively (overall 39%). There was a tendency for higher covariate (age, body mass index, albuminuria, hematocrit, alcohol consumption, smoking, diabetes mellitus, ischemic heart disease and antihypertensive medication) adjusted mean levels of diastolic blood pressure for the DD genotype in men but not in women. However, this tendency disappeared after dichotomization of blood pressure into diagnostic categories (normotension and hypertension). Results did not differ when the subjects were divided into two age groups (< or = 59 and > or = 60 years). Covariate-adjusted odds ratios for hypertension for presence of the D allele were close to the null value of one. ACE genetic variation accounted for only 0.1 and 0.7% of the inter-individual variation in systolic and diastolic blood pressure in men. These estimates were 0.2 and 0.1%, respectively, in women.

CONCLUSION

Although there is a tendency of higher diastolic blood pressure in men with DD genotypes, there is no convincing evidence that ACE genotypes are associated with hypertension in this Japanese population.

Serum vitamin C concentration was inversely associated with subsequent 20-year incidence of stroke in a Japanese rural community. The Shibata study

BACKGROUND AND PURPOSE

Epidemiological evidence suggests that vitamin C may decrease the risk of stroke. The purpose of the present study was to examine the association of serum vitamin C concentration with the subsequent incidence of stroke.

METHODS

In a Japanese rural community, a cohort of 880 men and 1241 women aged 40 years and older who were initially free of stroke was examined in 1977 and followed until 1997. The baseline examination included a measurement of serum vitamin C concentration. The incidence of stroke was determined by annual follow-up examinations and registry.

RESULTS

During the 20-year observation period, 196 incident cases of all stroke, including 109 cerebral infarctions and 54 hemorrhagic strokes, were documented. Strong inverse associations were observed between serum vitamin C concentration and all stroke (sex- and age-adjusted hazard ratios were 0.93, 0.72, and 0.59, respectively, for the second, third, and fourth quartiles compared with the first quartile; P for trend=0.002), cerebral infarction (0.71, 0.59, and 0.51; P for trend=0.015), and hemorrhagic stroke (0.89, 0.75, and 0. 45; P for trend=0.013). Additional adjustments for blood pressure, serum total cholesterol, body mass index, physical activity, smoking, alcohol drinking, antihypertensive medication, atrial fibrillation, and history of ischemic heart disease did not attenuate these associations markedly.

CONCLUSIONS

Serum vitamin C concentration was inversely related to the subsequent incidence of stroke. This relationship was significant for both cerebral infarction and hemorrhagic stroke. Additional mechanistic hypotheses may be required to explain our findings.

Leisure-time physical activity and related lifestyle characteristics among middle-aged Japanese. Japan Lifestyle Monitoring Study Group

The present study describes leisure-time physical activity status and related lifestyle factors in middle-aged Japanese. Data were obtained from 1,893 (905 men, 988 women) participants aged 40-69 years who had either been selected from a public registry or who had visited a healthcare facility. Subjects responded to a self-administered questionnaire and were interviewed using an assessment method for leisure-time and on-the-job physical activity within the last 12 months by trained interviewers. According to the leisure-time physical activity score, men and urban residents tended to engage in more leisure-time physical activity than did women and rural residents, respectively. Leisure-time physical activity tended to be inversely associated with on-the-job physical activity in all cases aside from women in urban regions, and also to be associated with higher levels of education in rural regions. Subjects engaging in more leisure-time physical activity had higher odds ratios of certain lifestyle factors, indicating a healthy lifestyle that included a variety of foods in their diet and a subjective sense of wellness in both men and women, in addition to non-smoking and drinking milk in men. These results suggested that leisure-time physical activity is influenced by socio-environmental factors, and that it is accompanied by other healthy behavior.

Population attributable fraction of stroke incidence in middle-aged and elderly people: contributions of hypertension, smoking and atrial fibrillation

We determined the population attributable fraction (PAF) of stroke due to hypertension (HT), atrial fibrillation (Af) and smoking in a Japanese community. Residents of Shibata (n = 2,302) who were surveyed initially in 1977 were followed until 1997. Two hundred and thirteen first strokes occurred. Among those 40-64 years of age, the risk ratio (RR) of Af was 11.24, followed by untreated HT (3.61), uncontrolled HT (3.69) and smoking (1.84). The PAFs, however, were 14.9% for smoking, 13.5% for untreated HT, 8.6% for uncontrolled HT and 3.6% for Af. Among those over 65 years, only Af was significant (RR 3.89) and the PAF was 6.0%. Determination of PAFs is also essential for designing effective stroke prevention programs in communities.

Erythrocyte sedimentation rate in healthy school children of Bangladesh

The reference value of erythrocyte sedimentation rate (ESR) should be established for a population concerned because it is influenced by many local conditions. It has not yet been determined in healthy children of Bangladesh. This study was done to determine the reference value of ESR in Bangladeshi children. ESR was determined in a sample of 413 'healthy' primary school students (259 boys and 154 girls, mean age 8.7 years). Ninety-five percent of them had ESR < or = 30 mm (Westergren 1 h). Our findings suggest that ESR value > 30 mm (Westergren 1 h) should be considered high in Bangladeshi primary school children.

Dietary intake and cancer mortality in Japan

We examined the correlation between the prefectural variation of standardized mortality ratio (SMR) for lung and colon cancer and the consumption of foods using dietary data from National Nutrition Survey in Japan from 1976 to 1995. We found partly the same results on promoting factors and preventing factors of these cancers as the previously reported large scale cohort studies. But, we also found the inconsistent results. This might be partly because of the limitation of data collection method in the National Nutrition Survey. It was thought that the method of National Nutrition Survey should be modified to monitor nutrition and health conditions to correspond the epidemiological study and to prevent chronic diseases.

Humoral immune response in a sample of Bangladeshi children with rheumatic fever

Several researchers have investigated cellular response, and antibody response to different antigens of group A beta-haemolytic streptococci, cardiac tissues and B cell alloantigen in rheumatic fever (RF). However, immunoglobulins (Ig) which may indicate general immune status did not receive attention. This study was done in the outpatient clinic of the National Center for Control of Rheumatic Fever and Heart Diseases, Dhaka, to compare Ig levels in subjects with and without RF who have had recent group A beta-haemolytic streptococcal infections. We have recruited 44 RF cases aged 5 to 20 years, and 44 subjects without RF were randomly matched for age and sex as controls. Convalescent blood samples were used to measure antistreptolysin O and IgG, IgM, and IgA levels. The cases, as compared with the controls, had significantly higher levels of antistreptolysin O (mean 399 versus 321 IU/ml), IgG (mean 2386 versus 1885 mg/dl), IgM (mean 286 versus 222 mg/dl) and IgA (mean 258 versus 184 mg/dl). It is not clearly known why the immune response is higher in the RF cases. We have to elucidate factors responsible for higher immune response in children with RF.

Association between health-related knowledge and the awareness of blood pressure readings. Japan Lifestyle Monitoring Study Group

This study aims to evaluate the relationships between awareness of blood pressure testing and health-related knowledge. Among 9 blocks in Japan, one or two areas were selected and a questionnaire survey including physical activity, nutrient intake, drinking habits, smoking habits, medical history, annual frequency of blood pressure testing, subjective sense of wellness, and health related knowledge was conducted. Respondents' sex and age were adjusted as potential confounding factors and the association between possession of health-related knowledge and awareness of blood pressure testing were examined by using a multiple logistic regression model. Among the 1,834 effective responses, 263 (14.3%) answered that they could state their blood pressure levels. These individuals tended to have a greater health-related knowledge. Even after adjusting for other potential confounders (smoking habits, medical history, annual frequency of blood pressure testing, and subjective sense of wellness) health-related knowledge were significantly related to blood pressure awareness.

Behavioral factors predicting serum cotinine concentrations of male smokers in a Japanese community

Cigarette-derived toxic substances are inhaled along with the nicotine that is absorbed to satisfy the smoker's physical demand. Therefore, serum cotinine, a metabolite of nicotine, may be considered to be an indirect marker of absorption of the other toxic substances from smoking. However, few studies have examined factors related to serum cotinine concentrations in natural settings. The authors, therefore, have studied relations among patterns of smoking behavior and serum cotinine concentrations of community residents. Subjects were 60 smoking men living in the town of Yamasaki, Hyogo Prefecture, Japan. Number of daily cigarettes, depth of inhalation, hours from the last cigarette smoked and the total nicotine tolerance score were significantly, while neither nicotine-yields nor butt length of a discarded cigarette was correlated with serum cotinine concentrations. Multiple regression analysis confirmed that depth of inhalation and hours from the last cigarette smoked were independently significant. This finding suggests that attention only to self-reported daily number of cigarettes smoked may not be sufficient to detect smokers who are actually at high risk. Healthcare workers should also pay attention to smokers' patterns of smoking, particularly depth of inhalation.

Association of angiotensin converting enzyme (ACE) gene polymorphism with hypertension in a Bangladeshi population

The association of angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism with hypertension has not been confirmed. Inconsistencies may be due to the differences of background population characteristics. Till date, there has been no report in Bangladeshi population. This study was to examine the association of ACE (I/D) polymorphism with hypertension. Fifty-one primary hypertensives and fifty-two normotensives were recruited from a hospital in Dhaka city. Height, weight and blood pressure were measured. ACE (I/D) genotypes was established using polymerase chain reaction protocol. The genotype and allele frequencies did not differ significantly (P > 0.05) between the groups. In logistic regression analysis, adjusted for age, sex and body mass index, the genotypes were not associated with hypertension (DD vs II: Adds ratio = 2.6, P = 0.34; ID vs II: 0.4, 0.23; ID + DD vs II: 0.8, 0.69). In this hospital-based sample of Bangladeshi people, significant association of ACE I/D genotype with hypertension was not observed.

An inverse relationship between serum vitamin C and blood pressure in a Japanese community

To examine the relationship between serum vitamin C concentration and blood pressure level, a cross-sectional study was conducted. The subjects were 919 men and 1,266 women aged 40 years and over in a Japanese provincial city, Shibata, Niigata Prefecture. The mean and standard deviation of systolic blood pressure (SBP) were 134.0 +/- 20.0 mmHg for men and 128.3 +/- 20.8 mmHg for women, and those of diastolic blood pressure (DBP) were 81.0 +/- 11.7 mmHg and 75.8 +/- 11.4 mmHg, respectively. The mean and standard deviation of serum vitamin C were 42.5 +/- 18.6 mumol/L for men and 56.8 +/- 16.5 mumol/L for women. SBP and DBP were both inversely correlated with serum vitamin C concentration. The means of SBP or DBP were calculated for quartiles of serum vitamin C, and the significant inverse relationship was observed in any sex and age group. The inverse association persisted after adjustment for possible confounders: body mass index, serum total cholesterol, alcohol consumption, smoking, physical activity, antihypertensive medication, and dietary intake of salt, calcium, and potassium. Serum vitamin C appeared to be inversely related with both SBP and DBP in this Japanese population, although further intervention and experimental studies were required to establish the cause-effect relationship.

Does rheumatic fever occur usually between the ages of 5 and 15 years?

It has long been considered that rheumatic fever usually occurs in children between the ages of 5 and 15 years. However, supporting data from the developing countries are insufficient. It is important to know the age of occurrence of rheumatic fever for clinical and public health purposes. To describe the age distribution of Bangladeshi subjects, we have reviewed the records of all patients who attended with acute rheumatic fever in the outpatient department of the National Center for Control of Rheumatic Fever and Heart Diseases, Dhaka, during June 1990 through November 1995. During this period 630 subjects were diagnosed to have acute rheumatic fever defined by the revised Jones criteria. Of them, 535 (84.9%) presented with first attack. Their age ranged from 3 to 30 years, and a skewness to the right of the age distribution was observed. Thus, we used percentile distribution to determine reference range of age. The 2.5 and 97.5 percentiles were 5 and 22 years, respectively. Their mean (standard deviation) and median age were 12.7 (4.4) and 12 years, respectively. Slightly more than 22% of subjects were older than 15 while less than 1% were younger than 5 years. This finding was supported by multiethnic data from other developing countries. The current analysis warrants reevaluation of the prevailing conviction for age of occurrence of rheumatic fever. In conclusion, the age reference range for occurrence of rheumatic fever in Bangladesh should be considered to be 5 to 22 years but not 5 to 15 years.

Trends of average intake of macronutrients in 47 prefectures of Japan from 1975 to 1994--possible factors that may bias the trend data

To describe the geographical patterns and trends of macronutrient intake in Japan for the recent 20 years, we analyzed the data sets of the National Nutrition Surveys (J-NNS). First, we calculated regression coefficients for survey year by prefecture for energy, protein, fat, and carbohydrate intake. These results, however, could be affected by the changes in age and sex distributions of the survey samples. Secondly, as the food consumption data were based on household as a unit, we used proportions of the subjects who belong to age-specific groups and female subjects in a sub-sample for each prefecture in a given year for adjustment by general lineal model. As a result, 1% increase in the subjects aged 1-4, 10-19 and 65- years and female subjects was equivalent to the changes in average energy intake by -5.88, +2.27, -1.45 and -1.62 kcal, respectively. After the adjustment for age and sex, number of significant negative coefficients among 47 prefectures decreased for energy and carbohydrate intake, and that of positive coefficients increased for fat intake. This suggested that unadjusted trend data might lead to an overestimation of decreasing trends of energy and carbohydrate intake, and an underestimation of increasing trend of fat intake in the recent 20 years.

An optimal cutoff point of expired-air carbon monoxide levels for detecting current smoking: in the case of a Japanese male population whose smoking prevalence was sixty percent

An optimal cutoff point of expired-air carbon monoxide (Ex-CO) for detecting smokers should be determined in terms of its sensitivity and specificity and the prevalence of smoking in the target population. The purpose of this study is to determine the optimal cutoff point of Ex-CO for detecting smoking males in a Japanese community whose smoking prevalence was over 50%. Among free-living residents in a rural population, "true smokers" determined by presence of cotinine in serum were 61% (n = 94). When Ex-CO at 7 ppm or over differentiated "smokers" from "non-smokers", sensitivity and specificity for detecting smokers was 0.93 and 0.95, respectively, which comprised the best Youden's index. This setting also produced the minimum percentage of misclassified cases. In conclusion, 7 ppm of Ex-CO, which is exceptionally low value relative to the western standard, appears to be the most optimal cutoff point for a survey in a population with such high smoking prevalence.

Determination of percent body fat by the newly developed sulfur hexafluoride dilution method and air displacement plethysmography

The reliability and validity of two newly developed densitometric methods for determining the human body volume and percent body fat (%FAT), the sulfur hexafluoride dilution method (SHF) and air displacement plethysmography (ADP), were evaluated in comparison with the underwater weighing method (UWW). Seven healthy male volunteers (age 31 to 44, mean height 166.0 cm, weight 61.4 kg) participated in this study. The same-day test-retest coefficients of variation (CVs) for body volume and %FAT measurements were not significantly different among the three methods. SHF and UWW showed a strong correlation in terms of body volume and %FAT, with the correlation coefficients (r) being 0.9997 and 0.986, respectively. The correlation between ADP and UWW was slightly weaker (r = 0.9997 for body volume and 0.907 for %FAT). However, body volumes measured by SHF and ADP were significantly different from that by UWW when compared by mean values. Such differences were also found for %FAT measurements. The regression lines of body volume measured by SHF and ADP on that by UWW were almost equivalent to the line of identity. However, those of %FAT measured by SHF and ADP on that by UWW were significantly different from the line of identity. Because the reliability of SHF and ADP appeared to be high, further validation and improvement are required and worth doing.

Descriptive epidemiology of body mass index in Japanese adults in a representative sample from the National Nutrition Survey 1990-1994

OBJECTIVE

To determine the prevalence of obesity and reference percentile curves of body mass index (BMI; kg/m2) in Japanese adults.

DESIGN

Cross-sectional nationwide surveys (The National Nutrition Survey, Japan) carried out in 1990-1994. A sample of 23,556 males and 28,751 females aged 15-84 y was used for this analysis.

RESULTS

The prevalence of grades 1 (BMI: 25.0-29.9), 2 (30.0-39.9) and 3 (> or = 40.0) overweight, was estimated to be 24.3%, 1.84% and 0.019% in males, respectively, and 20.2%, 2.87% and 0.032% in females, respectively, subjects aged 35-64 y after standardization to the age-distribution of the standard world population (WHO, 1993). The age-standardized prevalence of obesity (for BMI > or = 26.4, a criterion of the Japan Society for the Study of Obesity; and > or = 30.0 was 13.6% and 1.86% in males, respectively, and 13.5% and 2.90% in females, respectively, subjects aged 35-64 y.

CONCLUSIONS

The standardized prevalence of obesity (BMI > or = 30.0) in Japanese adults was quite low compared with the data in western populations.

Nutritional factors associated with rheumatic fever

The determinants for a child with group A beta-haemolytic streptococcal throat infection (BHS infection) to develop rheumatic fever (RF) remain unclear. In this case-control study, we deal with BHS infected children to examine whether nutritional factors are related to RF. In a RF hospital in Dhaka (Bangladesh) we examined 218 consecutive out-patients who had antecedent BHS infection. Sixty of them met the updated Jones criteria for RF (cases) while 104 did not (controls). Fifty-four possible RF patients were excluded. We used anthropometric measurements and a food frequency questionnaire to assess nutritional factors. Higher risk of RF was observed for low height for age (odds ratio 3.82, 95% confidence interval 1.73-8.42); low weight for age (2.41, 1.12-5.57); low upper arm circumference for age (3.76, 1.87-7.89); and low consumption of eggs (3.81, 1.95-7.63), milk (2.60, 1.36-5.08), chicken (2.62, 1.35-5.21), pulses (1.98, 1.03-3.84), fruits 2.29, 1.20-4.45), and ruti (home-made bread) (3.15, 1.61-6.34). Reduced risk was observed for soybean oil consumption (0.28, 0.12-0.62). The significant association of upper arm circumference and eggs persisted after adjustment for multiple sociodemographic confounders. The association of ruti and soybean oil appeared to be suggestive (0.05 < p < 0.1). Protein-energy malnutrition is likely to be associated with RF. The protective effect of moderate consumption of eggs and soybean oil may support other published work which suggests that the anti-inflammatory substance present in these food items may prevent maturation of the rheumatic process.

Association of apolipoprotein genetic polymorphisms with plasma cholesterol in a Japanese rural population. The Shibata Study

The association between apolipoprotein (apo) genetic polymorphisms and lipid phenotypes remains to be determined because such studies have reported contradictory results. We have measured plasma total cholesterol (TC) and HDL cholesterol (HDL-C) in a cross-sectional sample of 1328 (462 men and 866 women) Japanese (aged 40 to 80 years) and analyzed their DNA for the following genotypes: apoA1-C3 Msp I and Sst I sites; apoB signal peptide insertion/deletion, Xba I site and 3' variable number of tandem repeats (VNTR); and apoE. Using multivariate analyses (ANOVA) we found that (1) the polymorphisms of apoA1-C3 and apoB genes are not significantly associated with TC or HDL-C and (2) the polymorphism of the apoE gene is significantly related with TC and the TC:HDL-C ratio. The epsilon 2 carriers have lower levels of TC and a lower TC:HDL-C ratio, epsilon 3 carriers have intermediate levels, and epsilon 4 carriers have higher levels. These findings held whether sexes were analyzed separately or together. Although an opposite trend in HDL-C levels was observed, it did not reach the level of statistical significance. Multiple regression analyses have shown that apoE polymorphism accounts for about 2.3% of the variation in TC and TC:HDL-C ratio irrespective of sex. When the subjects are divided into two groups according to their age (< or = 59 and > or = 60 years old), the effect of apoE alleles on serum cholesterols appears to be diluted in the younger age group whereas it appears to be accentuated in the older group for both sexes. Our findings suggest that among the apo genetic polymorphisms examined, the apoE gene may be considered as a possible candidate for the "high-risk" strategy of atherosclerosis prevention in the Japanese population.

Quality control for blood pressure measurement in population studies: Shibata Children's Heart Study

To investigate the relation between observer performance for blood pressure measurement in a training process and in field conditions, measurement values were studied under training and field conditions among 21 blood pressure observers of 1434 subjects aged 6-15 years in Japan. The observers received training by a videotape, which included six audiovisual presentations of a falling mercury column in a standard sphygmomanometer with Korotkoff sounds. Observer bias was measured for each trainee as the mean difference between the observed and the standard values for each blood pressure reading, including systolic (SBP), fourth-phase diastolic (K4), and fifth-phase diastolic (K5) values. In multiple linear regression analyses, each 1 mmHg increment in observer bias was equivalent to 1.27, 0.88, and 1.25 mmHg difference in actual readings of SBP, K4, and K5, respectively, in the field. This finding indicates that observer performance in videotape training is predictive of measurement behavior in the field.

Socio-economic deprivation associated with acute rheumatic fever. A hospital-based case-control study in Bangladesh

There are few studies on the relationship between socio-economic factors and rheumatic fever (RF) in the populations where the burden of both socio-economic deprivation and RF is still very high. The aim of this study is to assess the association between some socio-economic factors and RF by examining data available from a RF hospital in Bangladesh. We have reviewed the medical records of patients presenting with manifestations suggestive of RF during a 1-year period. From the patients who showed group A beta-haemolytic streptococcal upper respiratory infection (ABHS infection), 44 RF cases defined by the Jones criteria and 86 control subjects, who did not satisfy the criteria, were identified for analysis. The median age was 12 years and 60% were female. RF was significantly associated with low income (odds ratio [OR] 2.37; P = 0.04); poor living conditions: substandard (kacha) house (OR 2.93, P = 0.02); and poor nutritional status: low height for age (OR 2.68, P = 0.02). Multiple logistic regression analysis revealed an increased OR for kacha house (OR 3.18, P = 0.02) but the same estimate for low height for age (OR 2.68; P = 0.04). Our analysis shows that, among the patients presenting to the RF hospital with proven ABHS infection, acute RF is associated with socio-economic deprivation.

Dietary lipids and incidence of cerebral infarction in a Japanese rural community

OBJECTIVE

To assess the relationship between dietary lipids and incidence of cerebral infarction in a Japanese rural population.

DESIGN

A cohort study from July 1977 through December 1992.

SETTING

Akadani-Ijimino (A-I) district, Niigata Prefecture, Japan.

SUBJECTS AND METHODS

All the residents, 1,182 men and 1,469 women, aged 40 years and over. Out of these members, 954 men and 1,329 women who were initially free of stroke completed a semiquantitative food frequency questionnaire in 1977, and were then subjected to a follow-up for 15.5 years. The occurrence of stroke was determined by the annual follow-up examination and registry. Dietary lipid was adjusted for total energy or fat intake by the residual method. Sex- and age-stratified and blood pressure- and atrial fibrillation-adjusted relative risk for cerebral infarction was estimated by the Cox proportional hazard model.

RESULTS

There were 75 new cases of cerebral infarction during the observation period. The relative risk for cerebral infarction was less than one in the highest quartile level of total fat, saturated fatty acids (S), Keys score and westernized dietary pattern: 0.68-0.94. It ranged between 1.36 and 1.57 in the highest level of polyunsaturated (P), n-3 and n-6 fatty acids, and P/S ratio.

CONCLUSION

This study suggests the possibility that the traditional Japanese diet, very low fat intake, was likely to increase the risk of stroke through the low level of serum cholesterol as an intermediary factor.

A 15.5-year follow-up study of stroke in a Japanese provincial city. The Shibata Study

BACKGROUND AND PURPOSE

Change toward Western lifestyles, particularly during the high economic growth period (approximately 1960 to 1975), dynamically altered stroke frequency and the distribution of risk factors in the Japanese. We reexamined their association after this environmental change by a cohort study.

METHODS

The cohort (2302 subjects) comprised residents aged 40 years or older of the Akadani-Ijimino district in Shibata City, Niigata Prefecture, Japan, who were followed up from 1977 for 15.5 years.

RESULTS

Crude incidence rates per 1000 person-years for all strokes were 5.22 for men and 4.36 for women (3.02 and 2.18 for cerebral infarction, 0.65 and 1.06 for intracerebral hemorrhage, and 0.41 and 0.34 for subarachnoid hemorrhage, respectively). Multivariate analyses performed with the Cox proportional hazard model revealed these risk factors to be independently significant: for cerebral infarction in men, age, blood pressure, atrial fibrillation, albuminuria, funduscopic abnormality, and current smoking: for cerebral infarction in women, age, atrial fibrillation, and history of ischemic heart disease; for intracerebral hemorrhage in men, age and funduscopic abnormality; for intracerebral hemorrhage in women, age, blood pressure, and light physical activity; for all strokes in men, age, blood pressure, atrial fibrillation, albuminuria, funduscopic abnormality, current smoking, and heavy physical activity; and for all strokes in women, age, atrial fibrillation, and light physical activity.

CONCLUSIONS

Most traditional risk factors, including blood pressure and its related organ diseases, were confirmed, but serum total cholesterol had almost no effect. Physical activity had both negative and positive effects on stroke risk. In these findings, however, some differences related to sex were also observed.

A brief review of epidemiological studies on ischemic heart disease in Japan

The age-adjusted death rate from ischemic heart disease in Japan is the lowest among developed countries and the rates have decreased since 1970. The incidences of myocardial infarction in selected populations ranged between 0.12 and 2.56 per 1,000 for middle-aged males, and between 0.00 and 1.52 per 1,000 for females. The incidences of sudden death within 24 hours were from 0.00 to 1.58 per 1,000 for males and from 0.00 to 0.76 per/1,000 for females. The incidences in Japanese populations appeared to be far below those in Western populations. In the Cox proportional hazard regression model, hypertension and smoking were selected as independent risk factors for myocardial infarction in an agricultural district. It was noteworthy that the level of serum cholesterol was not associated with development of myocardial infarction in rural areas. No positive relation between dietary fat and serum cholesterol was observed in school children, suggesting that growth, sexual maturation and others might be confounding variables between them. The levels of serum cholesterol for females were more affected by menopause than those of blood pressures and body mass index. Although some polymorphisms in selected candidate genes appeared to be associated with some serum lipids and apolipoproteins, the effect of individual RFLP on the inter-individual variations in serum traits was relatively subtle in comparison with that of lifestyle factors.