Mild-to-Moderate Kidney Dysfunction and Cardiovascular Disease: Observational and Mendelian Randomization Analyses

BACKGROUND

End-stage renal disease is associated with a high risk of cardiovascular events. It is unknown, however, whether mild-to-moderate kidney dysfunction is causally related to coronary heart disease (CHD) and stroke.

METHODS

Observational analyses were conducted using individual-level data from 4 population data sources (Emerging Risk Factors Collaboration, EPIC-CVD [European Prospective Investigation into Cancer and Nutrition-Cardiovascular Disease Study], Million Veteran Program, and UK Biobank), comprising 648 135 participants with no history of cardiovascular disease or diabetes at baseline, yielding 42 858 and 15 693 incident CHD and stroke events, respectively, during 6.8 million person-years of follow-up. Using a genetic risk score of 218 variants for estimated glomerular filtration rate (eGFR), we conducted Mendelian randomization analyses involving 413 718 participants (25 917 CHD and 8622 strokes) in EPIC-CVD, Million Veteran Program, and UK Biobank.

RESULTS

There were U-shaped observational associations of creatinine-based eGFR with CHD and stroke, with higher risk in participants with eGFR values <60 or >105 mL·min-1·1.73 m-2, compared with those with eGFR between 60 and 105 mL·min-1·1.73 m-2. Mendelian randomization analyses for CHD showed an association among participants with eGFR <60 mL·min-1·1.73 m-2, with a 14% (95% CI, 3%-27%) higher CHD risk per 5 mL·min-1·1.73 m-2 lower genetically predicted eGFR, but not for those with eGFR >105 mL·min-1·1.73 m-2. Results were not materially different after adjustment for factors associated with the eGFR genetic risk score, such as lipoprotein(a), triglycerides, hemoglobin A1c, and blood pressure. Mendelian randomization results for stroke were nonsignificant but broadly similar to those for CHD.

CONCLUSIONS

In people without manifest cardiovascular disease or diabetes, mild-to-moderate kidney dysfunction is causally related to risk of CHD, highlighting the potential value of preventive approaches that preserve and modulate kidney function.

The association of pure fruit juice, sugar-sweetened beverages and fruit consumption with asthma prevalence in adolescents growing up from 11 to 20 years: The PIAMA birth cohort study

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Pure fruit juice was consumed most frequently at the age of 14.

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Consumption of fruit was not associated with asthma from 11 to 20 years.

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Consumption of SSBs was not associated with asthma from 11 to 20 years.

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Consumption of pure fruit juice was not associated with asthma from 11 to 20 years.

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We found no evidence for limiting pure fruit juice consumption to prevent asthma.

Pure fruit juice is comparable to sugar-sweetened beverages (SSBs) with respect to its sugar and fructose content. However, it also contains favorable components like polyphenols. From this perspective, pure fruit juice is more comparable with whole fruit. SSBs have been associated with higher asthma risk, while whole fruit consumption has been associated with lower prevalence of asthma (symptoms). Associations with pure fruit juice have been rarely studied. Therefore, we studied the associations of consumption of pure fruit juice, SSBs and whole fruit with asthma prevalence in 3046 children of the Dutch Prevention and Incidence of Asthma and Mite Allergy (PIAMA) birth cohort growing up from 11 to 20 years. Consumption of pure fruit juice, SSBs and fruit was self-reported at the ages of 11, 14, 17 and 20 years. Presence of asthma was defined based on parental reports of asthma diagnosis ever, and wheezing and asthma medication in the last 12 months. Odds ratios (OR) were estimated using generalized linear mixed models accounting for correlation between repeated measurements within subjects. No associations were found between pure fruit juice, SSBs and fruit consumption and the overall prevalence of asthma from 11 to 20 years. An earlier reported association of low pure fruit juice consumption with higher asthma prevalence at the age of 11 years in the PIAMA population was confirmed, but no associations were found at the ages of 14, 17 and 20 years.

Type 2 Diabetes Partitioned Polygenic Scores Associate With Disease Outcomes in 454,193 Individuals Across 13 Cohorts

OBJECTIVE

Type 2 diabetes (T2D) has heterogeneous patient clinical characteristics and outcomes. In previous work, we investigated the genetic basis of this heterogeneity by clustering 94 T2D genetic loci using their associations with 47 diabetes-related traits and identified five clusters, termed β-cell, proinsulin, obesity, lipodystrophy, and liver/lipid. The relationship between these clusters and individual-level metabolic disease outcomes has not been assessed.

RESEARCH DESIGN AND METHODS

Here we constructed individual-level partitioned polygenic scores (pPS) for these five clusters in 12 studies from the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium and the UK Biobank (n = 454,193) and tested for cross-sectional association with T2D-related outcomes, including blood pressure, renal function, insulin use, age at T2D diagnosis, and coronary artery disease (CAD).

RESULTS

Despite all clusters containing T2D risk-increasing alleles, they had differential associations with metabolic outcomes. Increased obesity and lipodystrophy cluster pPS, which had opposite directions of association with measures of adiposity, were both significantly associated with increased blood pressure and hypertension. The lipodystrophy and liver/lipid cluster pPS were each associated with CAD, with increasing and decreasing effects, respectively. An increased liver/lipid cluster pPS was also significantly associated with reduced renal function. The liver/lipid cluster includes known loci linked to liver lipid metabolism (e.g., GCKR, PNPLA3, and TM6SF2), and these findings suggest that cardiovascular disease risk and renal function may be impacted by these loci through their shared disease pathway.

CONCLUSIONS

Our findings support that genetically driven pathways leading to T2D also predispose differentially to clinical outcomes.

Preventing heart failure: a position paper of the Heart Failure Association in collaboration with the European Association of Preventive Cardiology

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present consensus document aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing HF are listed.

Adverse generational changes in obesity development converge at midlife without increased cardiometabolic risk

OBJECTIVE

Obesity is becoming a global public health problem, but it is unclear how it impacts different generations over the life course. Here, a descriptive analysis of the age-related changes in anthropometric measures and related cardiometabolic risk factors across different generations was performed.

METHODS

The development of anthropometric measures and related cardiometabolic risk factors was studied during 26 years of follow-up in the Doetinchem Cohort Study (N = 6,314 at baseline). All analyses were stratified by sex and generation, i.e., 10-year age groups (20-29, 30-39, 40-49, and 50-59 years) at baseline. Generalized estimating equations were used to test for generational differences.

RESULTS

Weight, BMI, waist circumference, and prevalence of overweight and obesity were higher, in general, in the younger generations during the first 10 to 15 years of follow-up. From age 50 to 59 years onward, these measures converged in all generations of men and women. Among cardiometabolic risk factors, only type 2 diabetes showed an unfavorable shift between the two oldest generations of men.

CONCLUSIONS

It was observed that, compared with the older generations, the younger generations had obesity at an earlier age but did not reach higher levels at midlife and beyond. This increased exposure to obesity was not (yet) associated with increased prevalence of cardiometabolic risk factors.

Consumption of Meat, Fish, Dairy Products, and Eggs and Risk of Ischemic Heart Disease

BACKGROUND

There is uncertainty about the relevance of animal foods to the pathogenesis of ischemic heart disease (IHD). We examined meat, fish, dairy products, and eggs and risk for IHD in the pan-European EPIC cohort (European Prospective Investigation Into Cancer and Nutrition).

METHODS

In this prospective study of 409 885 men and women in 9 European countries, diet was assessed with validated questionnaires and calibrated with 24-hour recalls. Lipids and blood pressure were measured in a subsample. During a mean of 12.6 years of follow-up, 7198 participants had a myocardial infarction or died of IHD. The relationships of animal foods with risk were examined with Cox regression with adjustment for other animal foods and relevant covariates.

RESULTS

The hazard ratio (HR) for IHD was 1.19 (95% CI, 1.06-1.33) for a 100-g/d increment in intake of red and processed meat, and this remained significant after exclusion of the first 4 years of follow-up (HR, 1.25 [95% CI, 1.09-1.42]). Risk was inversely associated with intakes of yogurt (HR, 0.93 [95% CI, 0.89-0.98] per 100-g/d increment), cheese (HR, 0.92 [95% CI, 0.86-0.98] per 30-g/d increment), and eggs (HR, 0.93 [95% CI, 0.88-0.99] per 20-g/d increment); the associations with yogurt and eggs were attenuated and nonsignificant after exclusion of the first 4 years of follow-up. Risk was not significantly associated with intakes of poultry, fish, or milk. In analyses modeling dietary substitutions, replacement of 100 kcal/d from red and processed meat with 100 kcal/d from fatty fish, yogurt, cheese, or eggs was associated with ≈20% lower risk of IHD. Consumption of red and processed meat was positively associated with serum non-high-density lipoprotein cholesterol concentration and systolic blood pressure, and consumption of cheese was inversely associated with serum non-high-density lipoprotein cholesterol.

CONCLUSIONS

Risk for IHD was positively associated with consumption of red and processed meat and inversely associated with consumption of yogurt, cheese, and eggs, although the associations with yogurt and eggs may be influenced by reverse causation bias. It is not clear whether the associations with red and processed meat and cheese reflect causality, but they were consistent with the associations of these foods with plasma non-high-density lipoprotein cholesterol and for red and processed meat with systolic blood pressure, which could mediate such effects.

Biomarkers of Dietary Omega-6 Fatty Acids and Incident Cardiovascular Disease and Mortality

BACKGROUND

Global dietary recommendations for and cardiovascular effects of linoleic acid, the major dietary omega-6 fatty acid, and its major metabolite, arachidonic acid, remain controversial. To address this uncertainty and inform international recommendations, we evaluated how in vivo circulating and tissue levels of linoleic acid (LA) and arachidonic acid (AA) relate to incident cardiovascular disease (CVD) across multiple international studies.

METHODS

We performed harmonized, de novo, individual-level analyses in a global consortium of 30 prospective observational studies from 13 countries. Multivariable-adjusted associations of circulating and adipose tissue LA and AA biomarkers with incident total CVD and subtypes (coronary heart disease, ischemic stroke, cardiovascular mortality) were investigated according to a prespecified analytic plan. Levels of LA and AA, measured as the percentage of total fatty acids, were evaluated linearly according to their interquintile range (ie, the range between the midpoint of the first and fifth quintiles), and categorically by quintiles. Study-specific results were pooled using inverse-variance-weighted meta-analysis. Heterogeneity was explored by age, sex, race, diabetes mellitus, statin use, aspirin use, omega-3 levels, and fatty acid desaturase 1 genotype (when available).

RESULTS

In 30 prospective studies with medians of follow-up ranging 2.5 to 31.9 years, 15 198 incident cardiovascular events occurred among 68 659 participants. Higher levels of LA were significantly associated with lower risks of total CVD, cardiovascular mortality, and ischemic stroke, with hazard ratios per interquintile range of 0.93 (95% CI, 0.88-0.99), 0.78 (0.70-0.85), and 0.88 (0.79-0.98), respectively, and nonsignificantly with lower coronary heart disease risk (0.94; 0.88-1.00). Relationships were similar for LA evaluated across quintiles. AA levels were not associated with higher risk of cardiovascular outcomes; in a comparison of extreme quintiles, higher levels were associated with lower risk of total CVD (0.92; 0.86-0.99). No consistent heterogeneity by population subgroups was identified in the observed relationships.

CONCLUSIONS

In pooled global analyses, higher in vivo circulating and tissue levels of LA and possibly AA were associated with lower risk of major cardiovascular events. These results support a favorable role for LA in CVD prevention.

Adult height, coronary heart disease and stroke: a multi-locus Mendelian randomization meta-analysis

Background: We investigated causal effect of completed growth, measured by adult height, on coronary heart disease (CHD), stroke and cardiovascular traits, using instrumental variable (IV) Mendelian randomization meta-analysis.

Methods: We developed an allele score based on 69 single nucleotide polymorphisms (SNPs) associated with adult height, identified by the IBCCardioChip, and used it for IV analysis against cardiovascular risk factors and events in 21 studies and 60 028 participants. IV analysis on CHD was supplemented by summary data from 180 height-SNPs from the GIANT consortium and their corresponding CHD estimates derived from CARDIoGRAMplusC4D.

Results: IV estimates from IBCCardioChip and GIANT-CARDIoGRAMplusC4D showed that a 6.5-cm increase in height reduced the odds of CHD by 10% [odds ratios 0.90; 95% confidence intervals (CIs): 0.78 to 1.03 and 0.85 to 0.95, respectively],which agrees with the estimate from the Emerging Risk Factors Collaboration (hazard ratio 0.93; 95% CI: 0.91 to 0.94). IV analysis revealed no association with stroke (odds ratio 0.97; 95% CI: 0.79 to 1.19). IV analysis showed that a 6.5-cm increase in height resulted in lower levels of body mass index (P < 0.001), triglycerides (P < 0.001), non high-density (non-HDL) cholesterol (P < 0.001), C-reactive protein (P = 0.042), and systolic blood pressure (P = 0.064) and higher levels of forced expiratory volume in 1 s and forced vital capacity (P < 0.001 for both).

Conclusions: Taller individuals have a lower risk of CHD with potential explanations being that taller people have a better lung function and lower levels of body mass index, cholesterol and blood pressure.

Statin use and markers of immunity in the Doetinchem cohort study

It has been suggested that statins can both stimulate and suppress the immune system, and thereby, may influence autoimmune diseases. Therefore, we studied effects of statins on innate and adaptive immunity, and self-tolerance by measuring serological levels of C-reactive protein (CRP), neopterin, immunoglobulin E (IgE) antibodies and the presence of autoantibodies (antinuclear antibodies (ANA) and IgM rheumatoid factor (RF)) in the general population. We conducted a nested case-control study within the population-based Doetinchem cohort. Data from health questionnaires, serological measurements and information on medication from linkage to pharmacy-dispensing records were available. We selected 332 statin users (cases) and 331 non-users (controls), matched by age, sex, date of serum collection, history of cardiovascular diseases, diabetes mellitus type II and stroke. Multivariate regression analyses were performed to estimate effect of statins on the immune system. The median level of CRP in statin users (1.28 mg/L, interquartile range (IQR): 0.59-2.79) was lower than in non-users (1.62 mg/L, IQR: 0.79-3.35), which after adjustment was estimated to be a 28% lower level. We observed an inverse association between duration of statin use and CRP levels. Elevated levels of IgE (>100 IU/mL) were more prevalent in statin users compared to non-users. A trend towards increased levels of IgE antibodies in statin users was observed, whereas no associations were found between statin use and levels of neopterin or the presence of autoantibodies. In this general population sub-sample, we observed an anti-inflammatory effect of statin use and a trend towards an increase of IgE levels, an surrogate marker for Th (helper) 2 responses without a decrease in neopterin levels, a surrogate marker for Th1 response and/or self-tolerance. We postulate that the observed decreased inflammatory response during statin therapy may be important but is insufficient to induce loss of self-tolerance.

Comparison of different methods to estimate prevalence of drug use by using pharmacy records

Several methods to estimate prevalence of drug use are available, which may complicate a valid comparison of these estimates. Standardization may contribute to more valid comparisons. We compared different methods to estimate prevalence of drug use by using pharmacy records. Data were obtained from the Dutch population-based PHARMO-database comprising medication histories of 300,000 subjects. Five point prevalences and a 1-year prevalence of cholesterol-lowering drug use were estimated in 1995. Four point prevalences differed in data handling before estimating prevalence (e.g., correction for irregular drug use or construction of episodes of drug use). The numerator of the fifth point prevalence estimate represented the number of defined daily doses (DDDs) instead of the number of patients filling a prescription. The first four point prevalences ranged from 11.0-12.1 per thousand. Prevalence ratio (male:female) was 1.2 for these methods. The fifth method resulted in an estimate similar to the other point prevalences (11.9 DDDs/1000 inhabitants). However, the prevalence ratio was 1.4 due to larger average number of DDDs prescribed to men. One year-prevalence was 4-5 per thousand higher than point prevalences. The comparison of these methods indicated that the choice of prevalence measure (point versus period prevalence) substantially influenced the prevalence estimate, whereas the influence of data handling was negligible. For standardization purposes in drug utilization research, we recommend estimating point prevalence instead of period prevalence. The various methods of data handling before estimating point prevalence yielded similar results and therefore we cannot recommend one specific method. However, defined daily doses should not be used to estimate (point) prevalences of drug use because this measure is significantly influenced by prescribed dosage regimens.

Trends in total and high density lipoprotein cholesterol and their determinants in The Netherlands between 1993 and 1997

BACKGROUND

The aim of this study is to describe trends in plasma total and high density lipoprotein (HDL) cholesterol in The Netherlands between 1993 and 1997 and to examine whether these trends in cholesterol could be explained by changes in body mass index, smoking, alcohol intake, use of cholesterol lowering medication, intake of saturated fat, trans fatty acids and dietary cholesterol.

METHODS

Each year a random sample of men and women aged 20-59 years living in three towns in The Netherlands was invited to participate in the study. In total more than 21 000 people were examined.

RESULTS

Between 1993 and 1997 plasma total cholesterol decreased significantly by 0.19 mmol/l in men and by 0.27 mmol/l in women. During this period HDL cholesterol remained stable in both men and women. Small decreases were observed in the intake of saturated fat, trans fatty acids and dietary cholesterol in both men and women. The use of cholesterol lowering medication and for women oral contraceptives and prescribed oestrogens increased significantly. After adjustment for these determinants in multivariate analyses the trend in total cholesterol remained highly significant.

CONCLUSIONS

Between 1993 and 1997 the mean total cholesterol level decreased significantly while the mean HDL cholesterol remained stable in both men and women in The Netherlands. The observed trend in total cholesterol could only for a small part be explained by changes in the determinants studied.

Lifestyle factors and plasma homocysteine concentrations in a general population sample

The authors cross-sectionally investigated the extent to which coffee, tea, and alcohol consumption, physical activity, and smoking were associated with nonfasting total plasma homocysteine concentrations in a random sample of 3,025 Dutch adults aged 20--65 years from a population-based cohort examined in 1993--1996 (n = 19,066). The lifestyle factors most strongly associated with plasma total homocysteine level were smoking (positive), alcohol drinking (negative), and coffee consumption (positive). The smoking effect was most prominent in women, and the alcohol effect was most pronounced in men. Data indicated that independently of other lifestyle factors, age, and intake of folate and B vitamin supplements, a change in lifestyle could result in a 0.1- to 1.7-micromol/liter change in plasma total homocysteine level. The authors conclude that lifestyle changes could result in a public-health-relevant change in plasma total homocysteine concentrations.

Association between B vitamin intake and plasma homocysteine concentration in the general Dutch population aged 20-65 y

BACKGROUND

An elevated plasma total homocysteine (tHcy) concentration is associated with an increased risk of cardiovascular diseases. Folate, riboflavin, vitamin B-6, and vitamin B-12 are essential in homocysteine metabolism.

OBJECTIVE

The objective was to describe the association between dietary intakes of folate, riboflavin, vitamin B-6, and vitamin B-12 and the nonfasting plasma tHcy concentration.

DESIGN

A random sample of 2435 men and women aged 20-65 y from a population-based Dutch cohort examined in 1993-1996 was analyzed cross-sectionally.

RESULTS

Univariately, intakes of all B vitamins were inversely related to the plasma tHcy concentration. In multivariate models, only folate intake remained inversely associated with the plasma tHcy concentration. Mean plasma tHcy concentrations (adjusted for intakes of riboflavin, vitamin B-6, vitamin B-12, and methionine and for age, smoking, and alcohol consumption) in men with low (first quintile: 161 microg/d) and high (fifth quintile: 254 microg/d) folate intakes were 15.4 and 13.2 micromol/L, respectively; in women, plasma tHcy concentrations were 13.7 and 12.4 micromol/L at folate intakes of 160 and 262 microg/d, respectively. In men, the difference in the mean plasma tHcy concentration between men with low and high folate intakes was greater in smokers than in nonsmokers (2.8 compared with 1.6 micromol/L) and greater in nondrinkers than in drinkers of >2 alcoholic drinks/d (3.5 compared with 1.4 micromol/L). In women, the association between folate intake and plasma tHcy was not modified by smoking or alcohol consumption.

CONCLUSIONS

In this Dutch population, folate was the only B vitamin independently inversely associated with the plasma tHcy concentration. Changing dietary habits may substantially influence the plasma tHcy concentration in the general population.

The homocysteine distribution: (mis)judging the burden

The nonfasting plasma total homocysteine (P-tHcy) concentration was measured in a random sample of 3025 Dutch adults aged 20-65 years (main study). The positively skewed distribution had a geometric mean of 13.9 micromol/L in men and 12.6 micromol/L in women. Blood of the main study was not cooled or centrifuged immediately after drawing. A stability study (n = 26) indicated that this could have resulted in a small (0.4 micromol/L) overestimation of the means. A comparative study (n = 88), and a reproduction of these results in an entirely different population (n = 213), showed a systematic difference in P-tHcy concentration of -2.4 micromol/L between our laboratory (Nijmegen, the Netherlands) and that in Bergen, Norway. With the information of the additional studies we provided precise and valid data of the Dutch P-tHcy distribution, from which we conclude the status in the Netherlands is worse than in other European countries. Furthermore, we showed that comparison of P-tHcy data is complicated unless the interlaboratory differences are known. @ 2001 Elsevier Science Inc.

Obesity and other health determinants across Europe: the EURALIM project

STUDY OBJECTIVE

EURALIM (EURope ALIMentation), a European collaborative study, aimed to determine and describe the extent to which European data on risk factor distributions from different populations could be pooled and harmonised in a common database for international comparisons.

SETTING

Seven independent population-based surveys from six European countries (France, Italy, Northern Ireland/United Kingdom, Spain, Switzerland, the Netherlands).

METHODS

Data for 18 381 women and 12 908 men aged 40-59 were pooled in a common database. Central statistical analyses on major cardiovascular risk factors were conducted with careful consideration of methodological issues, including differences in study designs, data assessment tools, and analytic techniques used.

MAIN RESULTS

Because of the detected variability among methods used, direct comparisons of risk factor distributions and prevalences between studies were problematic. None the less, comparisons of within population contrasts by sex, age group, and other health determinants were considered to be meaningful and apt, as illustrated here for obesity. Results were targeted and disseminated to both the general public and public health professionals and framed in the context of a European information campaign.

CONCLUSIONS

International and national comparisons between existing locally run studies are feasible and useful, but harmonisation methods need improvement. Development of an international risk factor surveillance programme based on decentralised data collection is warranted. In the meantime, risk factor contrasts across populations can be used as a basis for targeting needed public health intervention programmes.

Total but not high-density lipoprotein cholesterol is consistently associated with coronary heart disease mortality in elderly men in Finland, Italy, and The Netherlands

We studied the relation between serum total and high-density lipoprotein (HDL) cholesterol and 10-year coronary heart disease mortality in elderly men in different European countries. The Finland, Italy and the Netherlands Elderly (FINE) Study is a prospective follow-up study in 2,132 elderly men ages 65-84 years in Finland, the Netherlands, and Italy. We estimated relative risks using Cox proportional hazard analysis with time-dependent covariates. Total cholesterol was positively related to coronary heart disease mortality in all three countries. The combined relative risk for the total population of the FINE Study was 1.17 (95% confidence interval = 1.06-1.29) for each 1.00 mmol/liter increase in total cholesterol. HDL cholesterol was inversely related to coronary heart disease mortality in Finland, but not in the Netherlands and Italy. In Italy we noted an interaction among HDL cholesterol, body mass index, and alcohol intake, with an inverse association for HDL cholesterol in lean men who drank <40 gm of alcohol daily and a positive association for HDL cholesterol among overweight men who drank > or =40 gm of alcohol per day. Serum total cholesterol remains an important predictor of coronary heart disease mortality in elderly men in different European countries. The effect of HDL cholesterol differed among the three countries.

The joint impact of family history of myocardial infarction and other risk factors on 12-year coronary heart disease mortality

We investigated the impact of family history of myocardial infarction on 12-year coronary heart disease mortality. Men and women with a family history had an increased risk for coronary heart disease death, irrespective of other risk factors (RR = 1.58; 95% CI = 1.17-2.13 and RR = 2.12; 95% CI = 1.11-4.05, respectively). Women with a family history seemed to be more susceptible to the detrimental effects of smoking; not to the effects of other risk factors. We found no effect modification by family history in men.

Serum cholesterol is a risk factor for myocardial infarction in elderly men and women: the Rotterdam Study

OBJECTIVE

To investigate the associations of serum total and HDL cholesterol with the risk of myocardial infarction in men and women of 55 years and over.

DESIGN

The Rotterdam Study is a population-based prospective cohort study. In total 2453 men and 3553 women of 55 years and older were included in this study. The mean duration of follow-up was 4 years.

MAIN OUTCOME MEASURES

Relative risks were estimated with Cox's proportional-hazard analysis. Cholesterol was analysed as a continuous variable and in sex-specific quartiles.

RESULTS

In subjects aged 55 years and older the relative risk of myocardial infarction was 1.9 in men (95% confidence interval 1.1-3.3) and 3.2 in women (1.5-6.4) in the highest compared to the lowest serum total cholesterol quartile (Q4 vs. Q1). In men and women of 70 years and older, total cholesterol remained an important risk factor for myocardial infarction (Q4 vs. Q1 relative risk 3.2; 1.3-7.7 and 2.9; 1.3-6.6, respectively). For HDL cholesterol, the relative risk in the highest compared to the lowest quartile (Q4 vs. Q1) was 0.5 in men (0.3-0.9) and 0.4 in women (0.2-0.9). HDL cholesterol was a weaker predictor in men after the age of 70 (Q4 vs. Q1 0.8; 0.3-2.1). In women of 70 years and older the relative risk was also not significant (Q4 vs. Q1 0.6; 0.3-1.3), although the trend over the quartiles was still significant.

CONCLUSION

Serum total cholesterol remains an important risk factor for myocardial infarction in men and women aged 70 years and older, whilst HDL cholesterol at older age remains important in women only.

[Risk factors for cardiovascular diseases in Turks in Amsterdam and in Ankara]

OBJECTIVE

To determine the prevalence of the main risk factors for cardiovascular disease in Turks in Amsterdam and in Ankara, and to compare the results obtained in these two groups with each other and also with those obtained in a group of indigenous Dutch residents living in the same districts.

DESIGN

Cross-sectional observational study.

SETTING

Districts 'Oost' and 'De Pijp' in Amsterdam, the Netherlands, 'Camlik' and 'Beşikkaya' in Ankara, Turkey.

METHODS

Plasma glucose and lipids were determined in 149 Turkish residents living in Amsterdam and 145 Turkish subjects in Ankara with comparable socio-economic status (66 and 74% of those who were asked to participate). Blood pressure was also measured by mercury sphygmomanometry. Questionnaires were completed on smoking habits, alcohol consumption, physical activity, consumption of food containing saturated fat, and the existence of heart and vascular disease or hypertension. Results were compared between groups and also with the findings obtained in a group of indigenous Dutch subjects living in the same districts in Amsterdam by the Peilstationsproject of the Rijksinstituut voor Volksgezondheid en Milieu (Sounding station project, National Institute for Public Health and the Environment).

RESULTS

Turkish men in Amsterdam had higher systolic blood pressures, lower HDL cholesterol values and higher total cholesterol/HDL cholesterol ratios, and were more obese than men in Ankara and Dutch men in Amsterdam. Glucose concentration and total cholesterol and LDL cholesterol concentrations of Turkish men in Amsterdam were higher than the values of men in Ankara. The risk profile of Turkish women was also more unfavourable compared with that of women in Ankara, but the differences were less than in the men. They had lower HDL cholesterol values, higher LDL cholesterol and glucose and smoked more often than women in Ankara. Turkish women in Amsterdam also had higher systolic and diastolic blood pressures and were more obese than Dutch women in Amsterdam.

CONCLUSION

Turkish residents in Amsterdam have more risk factors for cardiovascular disease than their countrymen living in Ankara, and also compared with indigenous Dutch citizens living in the same districts. Their risk factor profile, therefore, is not intermediary between that of Turkish subjects in Ankara and the indigenous Dutch citizens, as might be expected in view of the mortality figures.

Overweight, underweight, and mortality. A prospective study of 48,287 men and women

BACKGROUND

The relative contributions of a low and high body mass index (BMI [weight in kilograms divided by height in meters squared]) to all-cause and cause-specific mortality are still controversial.

OBJECTIVE

To examine mortality rates in relation to BMI in a prospective cohort study of 48,287 Dutch men and women aged 30 to 54 years at baseline from 1974 to 1980.

METHODS

During an average 12-year follow-up, 1319 deaths occurred. Relative risks (RRs) were calculated from the Cox proportional hazard model by using a BMI between 18.5 and 24.9 kg/m2 as the reference category.

RESULTS

All-cause mortality was significantly increased in obese men (BMI, > or = 30 kg/m2; RR, 1.5; 95% confidence interval [CI], 1.1-2.0) and in underweight men (BMI, < 18.5 kg/m2; RR, 2.6; 95% CI, 1.8-3.9) but not in women. The increased risk in underweight men could be attributed to deaths within the first 5 years of follow-up and to lung cancer mortality among smokers. Coronary heart disease (CHD) mortality was about 3-fold higher among obese men and women. About 21% and 28% of CHD mortality in men and women, respectively, could be attributed to being overweight (BMI, > or = 25 kg/m2). The RR (but not the absolute risk) for CHD among obese men was still significant after adjustment for the presence of smoking, hypertension, hypercholesterolemia, and diabetes mellitus at baseline, and it was more pronounced for CHD among nonsmokers than among smokers (RR, 7.1; 95% CI, 2.3-21.7; and RR, 2.7; 95% CI, 1.5-4.7, respectively).

CONCLUSIONS

Total mortality was increased in obese and underweight men but not in women. The increased mortality in overweight men was mainly attributable to CHD and, in underweight men, to early mortality and especially lung cancer mortality among smokers.

Prevalence and trends of obesity in The Netherlands 1987-1991

OBJECTIVE

To study the prevalence and trends in obesity in the period 1987-1991.

DESIGN

Linear regression of average body mass index (BMI in kg/m2) and prevalence of obesity (BMI > or = 30 kg/m2) in a continuous monitoring project in three towns in The Netherlands.

RESULTS

It was estimated that over the whole period the prevalence of obesity was 7% in men and 9% in women. After adjustment for age and educational level the prevalence of obesity increased significantly in both men with about 1.7 percentage points (+/- standard error: 0.8) and in women with 1.9 +/- 0.8 percentage points between 1987 and 1991. When stratified by 10-year age category the increase was strongest in those aged 20-29 and 50-59 years. When stratified by educational level, the increase was only significant in the lowest category (primary education and lower secondary education) and was not significant in other categories.

CONCLUSION

Obesity is relatively common in The Netherlands and, at least among responders to the yearly surveys, the prevalence of obesity has increased in the period 1987-1991 particularly in those with a relatively low educational level.

Serum total cholesterol and long-term coronary heart disease mortality in different cultures. Twenty-five-year follow-up of the seven countries study

OBJECTIVE

To compare the relationship between serum total cholesterol and long-term mortality from coronary heart disease (CHD) in different cultures.

DESIGN

Total cholesterol was measured at baseline (1958 through 1964) and at 5- and 10-year follow-up in 12,467 men aged 40 through 59 years in 16 cohorts located in seven countries: five European countries, the United States, and Japan. To increase statistical power six cohorts were formed, based on similarities in culture and cholesterol changes during the first 10 years of follow-up.

MAIN OUTCOME MEASURES

Relative risks (RRs), estimated with Cox proportional hazards (survival) analysis, for 25-year CHD mortality for cholesterol quartiles and per 0.50-mmol/L (20-mg/dL) cholesterol increase. Adjustment was made for age, smoking, and systolic blood pressure.

RESULTS

The age-standardized CHD mortality rates in the six cohorts ranged from 3% to 20%. The RRs for the highest compared with the lowest cholesterol quartile ranged from 1.5 to 2.3, except for Japan's RR of 1.1. For a cholesterol level of around 5.45 mmol/L (210 mg/dL), CHD mortality rates varied from 4% to 5% in Japan and Mediterranean Southern Europe to about 15% in Northern Europe. However, the relative increase in CHD mortality due to a given cholesterol increase was similar in all cultures except Japan. Using a linear approximation, a 0.50-mmol/L (20-mg/dL) increase in total cholesterol corresponded to an increase in CHD mortality risk of 12%, which became an increase in mortality risk of 17% when adjusted for regression dilution bias.

CONCLUSION

Across cultures, cholesterol is linearly related to CHD mortality, and the relative increase in CHD mortality rates with a given cholesterol increase is the same. The large difference in absolute CHD mortality rates at a given cholesterol level, however, indicates that other factors, such as diet, that are typical for cultures with a low CHD risk are also important with respect to primary prevention.

Total and HDL-cholesterol in The Netherlands: 1987-1992. Levels and changes over time in relation to age, gender and educational level

BACKGROUND

To gain insight into the prevalence of and trends in plasma cholesterol levels in the general population of the Netherlands, a monitoring project was carried out from 1987 to 1992.

METHODS

Each year a random sample of men and women aged 20-59 years in three towns in the Netherlands was invited to participate in the study. The overall response rate was 50% for men and 57% for women and a total of almost 42,000 men and women participated. Total (TC) and high density lipoprotein cholesterol (HDL-C) was measured and the non-HDL-C/HDL-C ratio was computed. Data were age-standardized to the Dutch population distribution aged 20-59 years.

RESULTS

The prevalence of hypercholesterolaemia (TC > or = 6.5 mmol/l) in men ranged from 5% in the youngest (20-29 years) to 29% in the oldest age group (50-59 years), and from 4% to 38% in women. Low HDL-C levels (< or = 0.9 mmol/l) in men ranged from 15% in the youngest to 26% in the oldest age group, and in women from 4% in the youngest to 7% in the oldest age group. The lipid profile of those with a higher educational level was more favourable than that of the less educated. From 1987 to 1992, in men, TC decreased by 0.12 mmol/l, HDL-C decreased by 0.07 mmol/l and the non-HDL-C/HDL-C ratio increased by 0.22. In women no statistically significant changes were observed. Changes over time did not differ according to age and educational level.

CONCLUSION

The prevalence of hypercholesterolaemia is still high in the Netherlands. During the period 1987-1992 the lipid profile worsened in men and remained stable in women.

Trends in blood pressure and the prevalence and treatment of hypertension in young adults in The Netherlands, 1974-1986

To investigate trends in blood pressure and the prevalence and treatment of hypertension in the Netherlands between 1974 and 1986, data from two screening projects on cardiovascular risk factors were used. Between 1974 and 1980 about 30,000 men and women aged 37-43 were screened. Between 1981-1986 about 80,000 men aged 33-37 were examined. An increase in average systolic blood pressure by 2 mmHg in men in the period 1974-1980 was followed by an insignificant change during the period 1981-1986. Average diastolic blood pressure increased by 4 mmHg between 1974 and 1980 but decreased by the same amount between 1981 and 1986. The prevalence of hypertension in 40-year-old men increased from 12.7% in 1974 to 17.8% in 1980. The prevalence of hypertension in 35-year-old men did not change between 1981 and 1986 and amounted to 9.6%. Treatment of 40-year-old hypertensive men increased from 8% in 1974 to 21% in 1980 and from 9% in 1981 to 13% in 1986 among 35-year-old men. Average systolic blood pressure did not change in 40-year-old women between 1974-1980 but average diastolic blood pressure increased by 2 mmHg during that period. The percentage of hypertensive women was 8.5% and did not change between 1974 and 1980. Also, the percentage of treated hypertensive women did not change and amounted to 28%.(ABSTRACT TRUNCATED AT 250 WORDS)

[The importance of HDL-cholesterol level determination in the classification of persons at increased risk of coronary heart disease]

The evidence is growing that not only total cholesterol, but also HDL cholesterol is an important predictor of coronary heart disease. In the Framingham Study, the total cholesterol/HDL cholesterol ratio gave the best prediction for the coronary heart disease risk. With data of the Netherlands Monitoring Risk Factor Project it was investigated to what extent persons with a high ratio (greater than or equal to 7) were identified when the criteria of the Netherlands Cholesterol Consensus were applied. Between 1987 and 1989 total and HDL cholesterol were determined in about 22,000 men and women aged 20-59. Twenty per cent of the men had hypercholesterolaemia (total cholesterol greater than or equal to 6.5 mmol/l). Of the hypercholesterolaemic men, 60 per cent did not have a high total/HDL cholesterol ratio. Eighteen per cent of the women were hypercholesterolaemic. Of all hypercholesterolaemic women, 80 per cent did not have a high total/HDL cholesterol ratio. Therefore, it is important that after a first screening on total cholesterol, HDL cholesterol is measured at the second cholesterol determination. Subsequently, a decision about treatment should be made, based on the total/HDL cholesterol ratio and the presence of other risk factors (hypertension, smoking, obesity, diabetes and a family history of cardiovascular disease.

Long-term follow-up of cardiovascular risk factors in patients given chemotherapy for disseminated nonseminomatous testicular cancer

OBJECTIVE

To assess cardiovascular risk factors over time in patients who received chemotherapy for disseminated testicular cancer and were apparently cured.

DESIGN

Cohort study.

SETTING

Referral center.

PATIENTS

Fifty-seven consecutive patients (median age, 28 years; range, 16 to 43 years) who received cisplatin-containing chemotherapy between 1978 and 1985.

MEASUREMENTS

Serum cholesterol and high-density lipoprotein (HDL) levels, body mass index (BMI), blood pressure, kidney function, and hormonal status were monitored during follow-up after chemotherapy (median follow-up, 88 months; range, 56 to 143 months). The BMI and cholesterol values obtained 4 to 6 years after chemotherapy were compared with values from a sample of healthy, age-matched Dutch men; the cholesterol level was also compared with that of 31 patients treated with orchidectomy for stage I disease.

RESULTS

The mean cholesterol level in patients at the start of chemotherapy was 3.96 +/- 0.98 mmol/L [153 +/- 38 mg/dL], increasing 4 to 6 years later to 6.12 +/- 1.20 mmol/L [237 +/- 46 mg/dL] (P less than 0.001); 49 of 57 patients had an elevated low-density lipoprotein (LDL) cholesterol level (greater than 3.4 mmol/L [130 mg/dL]), with a mean level of 4.47 +/- 1.05 mmol/L [173 +/- 41 mg/dL]. Compared with a sample of healthy Dutch men, the chemotherapy group had an elevated cholesterol level (P less than 0.05). At 4 to 6 years, the mean HDL cholesterol level was 0.76 +/- 0.18 mmol/L [29 +/- 7 mg/dL], which was low compared with that of the healthy Dutch men (P less than 0.05). The mean BMI for all patients was 2.8% higher than expected 4 to 6 years after chemotherapy (P less than 0.01) but was not higher than expected 7 to 10 years after chemotherapy.

CONCLUSIONS

In addition to other known late side effects of chemotherapy in patients with testicular cancer, hypercholesterolemia and overweight might represent risk factors for cardiovascular disease in such patients, especially in those who are younger.

Trend in serum total cholesterol level in 110,000 young adults in The Netherlands, 1974 to 1986

Data from two screening projects on cardiovascular risk factors were used to analyze the trend in serum total cholesterol level in the Netherlands between 1974 and 1986. Cholesterol levels were measured in a single reference laboratory of the World Health Organization throughout the entire study period. Between 1974 and 1980, about 30,000 men and women aged 37 to 43 years (mean age, approximately 40 years) were screened. A decrease in mean serum total cholesterol level was observed until the end of 1977, when it was followed by an increase. This resulted in a net change over the entire study period of -0.07 mmol/liter (3 mg/dl) in men and -0.03 mmol/liter (1 mg/dl) in women. Between 1981 and 1986, about 80,000 men aged 33 to 37 years (mean age, 35 years) were screened. During this period, a decrease of 0.20 mmol/liter (8 mg/dl) in the mean total cholesterol level was observed. In spite of the decline in the mean total cholesterol level, the prevalence of cholesterol values of greater than or equal to 6.5 mmol/liter (greater than or equal to 251 mg/dl) in young adult men was still high in 1986 (16 percent). A further reduction is therefore desirable. The decline in the mean total cholesterol level in young adults might indicate that a further decline in mortality from coronary heart disease can be expected.