Stroke risk in older men and women: aspirin, estrogen, exercise, vitamins, and other factors.

OBJECTIVE: To identify risk factors and preventive measures for stroke in elderly men and women. DESIGN: Observational prospective cohort study. SUBJECTS: Women (N = 8532) and men (N = 4722) between the ages of 44 and 101 (median age, 74) residing in a retirement community in southern California who had no previous history of stroke. METHODS: Upon entering the study in 1981, 1983, or 1985, study participants filled out a detailed health survey questionnaire about their medical history, exercise habits, intake of caffeinated beverages, alcohol, vitamins, and foods containing vitamins A or C, and history of smoking. Women also reported their use of estrogen replacement therapy. Cohort members were followed by periodic resurvey and by examination of death records through 1998. Age-adjusted stroke incidence rates, relative risks, and 2-sided P values were calculated. RESULTS: Between 1981 and 1998, 1211 women and 773 men were hospitalized for cerebrovascular disease. In women, risk of cerebral occlusion decreased significantly with increasing duration and recency of estrogen use. Hypertension, diabetes, heart attack, and smoking were significant stroke risk factors in both women and men. Exercise reduced stroke risk in general, and antioxidant vitamin supplements decreased the risk of cerebral occlusion. CONCLUSION: These results emphasize the role of lifestyle modification in the primary prevention of stroke and suggest that estrogen replacement therapy may be a potential preventive measure for women.

Clock drawing: analysis in a retirement community.

OBJECTIVE: To test the hypothesis that performance on a clock-drawing test in a mailed survey to an older cohort is associated with known and potential risk and protective factors for Alzheimer's disease. DESIGN: The Leisure World Cohort Study is an ongoing study, begun in 1981, of nearly 14,000 older adults. In November 1992, the 8,406 living cohort members were mailed a follow-up questionnaire. SETTING: Leisure World Laguna Hills, a southern California retirement community. PARTICIPANTS: The study population is a predominantly white, well-educated, upper-middle-class community; approximately two-thirds are women. Data from 4,843 cohort members (mean age 80 years; range 52-101) were analyzed. MEASUREMENTS: The questionnaire included a clock-drawing task: a predrawn circle 3 1/4 inches (8.3 cm) in diameter was provided with instructions "In the circle below, draw in the numbers as on a clock face. Make no erasures." Clocks were scored on 7 items: all numbers 1-12 present without adding extra or omitting numbers, sequencing of numbers, position of numbers, orientation of numbers to circle, consistent number style (either Arabic or Roman), tilt of numbers, and superfluous marks. A total clock score was calculated by summing the number of correct individual items (0-7). We also classified individuals as cognitively impaired by a previously suggested method: individuals were affected if they did not have three numbers drawn in the upper left quadrant of the clock face. RESULTS: Ninety percent or more of the participants across all ages placed the numbers 1 to 12 on their clocks without omissions or additions; 35% completed the clock drawing without error. The mean total clock scores decreased with each successive 5-year age group in both men and women. Regression analysis indicated a significant effect for age (b = -0.15, P <.0001), education (b = 0.05, P =.0001), smoking (b = 0.13, P =.03), and female gender (b = -0.05, P =.05) and a marginally significant effect of nonrheumatoid arthritis (b = 0.05, P =.07) on total clock score. No other measured variable had a significant effect. Cognitively impaired individuals were more likely to be female and older. After adjusting for age and gender, they were also more likely to be hypertensive and to have taken blood pressure medication and less likely to be college graduates, have glaucoma or arthritis, and to have taken vitamin supplements. CONCLUSION: The clock-drawing task is an appealing measure of cognitive function for large epidemiological studies because it is a simple, self-administered test that is easily adapted to mail surveys and correlates with more-detailed and more-time-consuming cognitive screens. Although it is relatively free of influence by language, cultural, or ethnic factors, our study shows that even in a highly educated population, clock drawing is influenced by educational level and other known risk factors for Alzheimer's disease. Thus a clock-drawing task may help predict cognitive frailty and future disability in older people. Such determination can direct high-risk individuals to earlier diagnosis, potential therapies, and better management.

A prospective study of pancreatic cancer in the elderly.

Risk factors for pancreatic cancer were examined in a cohort study of 13,979 residents of a retirement community. After 9 years of follow-up, 65 incident cases of pancreatic cancer were identified. An increased risk of pancreatic cancer was associated with a history of diabetes and cholecystectomy. Higher intake of vegetables, fruits, dietary beta-carotene, and vitamin C were each associated with a reduced risk of pancreatic cancer, although none of these associations was statistically significant. Risk of pancreatic cancer decreased with increasing tea consumption but was unrelated to coffee consumption. No strong or consistent association was seen between either smoking or alcohol consumption and risk of pancreatic cancer, but a consistent and significant increase in risk followed cholecystectomy.

Intake of vegetables, fruits, beta-carotene, vitamin C and vitamin supplements and cancer incidence among the elderly: a prospective study.

A cohort of 11,580 residents of a retirement community initially free from cancer were followed from 1981 to 1989. A total of 1,335 incident cancer cases were diagnosed during the period. Relative risks of cancer were calculated for baseline consumption of vegetables, fruits, beta-carotene, dietary vitamin C, and vitamin supplements. After adjustment for age and smoking, no evidence of a protective effect was found for any of the dietary variables in men. However, an inverse association was observed between vitamin C supplement use and bladder cancer risk. In women, reduced cancer risks of all sites combined and of the colon were noted for combined intake of all vegetables and fruits, fruit intake alone, and dietary vitamin C. Supplemental use of vitamins A and C showed a protective effect on colon cancer risk in women. There was some suggestion that beta-carotene intake and supplemental use of vitamin A, C, and E were associated with reduced risk of lung cancer in women, but none of these results were statistically significant. These inverse associations observed in women seem to warrant further investigation, although there was inconsistency in results between the sexes.

Aspirin use and chronic diseases: a cohort study of the elderly.

OBJECTIVE: To evaluate the associations between the use of aspirin and the incidences of cardiovascular diseases, cancers, and other chronic diseases. DESIGN: Postal questionnaire survey to elicit details of aspirin use. SETTING: Californian retirement community. SUBJECTS: All 22,781 residents of the community (white, affluent, and well educated) were sent a questionnaire that included questions on medical history and the use of drugs such as analgesics, laxatives, and vitamin supplements. In all 61% responded (13,987, 8881 women and 5106 men; median age 73). They formed the cohort that was followed up for 6 1/2 years using discharge summaries from three hospitals serving the area and death certificates from the health department. Only 13 respondents were lost to follow up but seemed not to have died. MAIN OUTCOME MEASURES: Incidences of cardiovascular diseases, cancers, gastrointestinal bleeding, ulcers, and cataracts were compared in participants who did and did not take aspirin daily. RESULTS: Age adjusted incidences were computed with an internal standard and five age groups. By 1 January 1988 there had been 25 incident cases of kidney cancer among all participants; 341 incident cases of stroke, 253 of acute myocardial infarction, 220 of ischaemic heart disease, and 317 of other heart disease were reported among respondents without a reported history of angina, myocardial infarction, or stroke. The incidence of kidney cancer was raised among those who took aspirin daily compared with those who did not take it, although the increase was significant only in men (relative risks = 6.3, 95% confidence interval 2.2 to 17, for men and 2.1, 0.53 to 8.5, for women). Those who took aspirin daily showed no increased risk of any other cancer, except colon cancer for both sexes combined (relative risk = 1.5, 1.1 to 2.2). The risk of acute myocardial infarction was reduced slightly among regular users of aspirin in men but not women. The risk of ischaemic heart disease was almost doubled in those who took aspirin daily compared with non-users (relative risks = 1.9, 1.1 to 3.1, for men and 1.7, 1.1 to 2.7, for women). Small, non-significant increased risks of stroke were observed in both sexes. CONCLUSION: The daily use of aspirin increased the risk of kidney cancer and ischaemic heart disease.

Analgesics, cigarette smoking, and other risk factors for cancer of the renal pelvis and ureter.

Results from a population-based case-control study of cancer of the renal pelvis and ureter are reported. Telephone interviews were conducted with 187 residents of Los Angeles County diagnosed with cancer of the renal pelvis and ureter over a 4-year period ending December 31, 1982, and with individually sex-, age- and race-matched neighborhood controls. The major risk factor identified for cancer of the renal pelvis and ureter was cigarette smoking. Subjects who smoked more than 25 years had a relative risk of 4.5 of developing these tumors, compared to nonsmokers (P less than 0.0001). Heavy use of over-the-counter analgesics was also associated with a significant increase in risk; it appears that an elevated risk was conveyed by all the major active constituents of those compounds currently marketed in the United States, aspirin, caffeine, and acetaminophen. Persons who had used these drugs for 30 consecutive days at any time in their life preceding diagnosis had twice the risk of developing cancer of the renal pelvis or ureter compared to persons not reporting such use (P less than 0.01). Heavy coffee drinkers (greater than or equal to 7 cups/day) had a 1.8-fold increase in risk compared to nondrinkers. Although risk tended to increase with increasing consumption, this result was not statistically significant. The risk associated with heavy coffee consumption was reduced to 1.3 after adjusting for smoking. Nine cases compared to no controls reported a first degree relative with kidney cancer. A history of kidney stones was associated with an increased risk of cancer of the ureter (relative risk = 2.5) that was not, however, statistically significant.

Vitamin A, beta-carotene, and the risk of cancer: a prospective study.

A cohort of 10,473 residents of Leisure World, Laguna Hills, CA, who were initially free of cancer were followed from 1981 to 1986. A health survey questionnaire completed by all cohort members included usual frequencies of consumption of certain food items, including vegetables, fruits, dairy products, liver, and cereal, as well as specific information on brand and formulation of vitamin supplements containing vitamins A, C, or E. Pathologic diagnosis of incident cancer was confirmed in 643 persons (56 lung, 110 colon, 59 bladder, 93 prostate, 123 female breast, and 202 cancers of other sites). Our study found little indication that increased intake of vitamin A or beta-carotene from the diet or supplements protects against the development of cancer overall. Dietary vitamin A intake was highly associated with smoking status; 25% of current smokers were in the highest third of dietary vitamin A consumption versus 32% of past smokers and 36% of never-smokers. In males who never smoked there was some indication that cancer rates decreased with increasing vitamin A intake, but the results were not statistically significant.

Alcohol, physical activity and other risk factors for colorectal cancer: a prospective study.

The aetiology of colorectal cancer was studied in a cohort of 11,888 residents of a retirement community. After four and one-half years of follow-up, 58 male and 68 female incident colorectal cancers were identified. Daily alcohol drinkers experienced nearly a two-fold increase in risk (2 sided P = 0.002). Colorectal cancer was also positively associated with Quetelet's index and inversely associated with avocational physical activity. The results were consistent for both sexes but were statistically significant only for males. With the exception of dietary vitamin C, none of the nutrients under study (i.e., vitamins A and E, dietary fibre, calcium, and beta carotene) showed a significant association with colorectal cancer. An inverse relationship between colorectal cancer and dietary vitamin C was observed in females, but there was no association with either vitamin C from supplements or with total vitamin C intake. Males and females who had 3 or more children showed a significantly reduced risk of colorectal cancer (RR = 0.45, 95% CI = 0.2, 0.9), but those with no children did not show the highest risk.

Vitamin supplement use in a Southern California retirement community.

Vitamin supplement were taken regularly by 62% of men and 69% of women surveyed in a Southern California retirement community. Supplement use was associated with more frequent use of health screening procedures and with several other health-related habits. A substantial proportion of residents consumed high levels of vitamins C and E, and 3.2% consumed potentially toxic doses of vitamin A.

Vitamin A and cancer incidence in a retirement community.

The use of vitamin A supplements and the risk of cancer was examined in a cohort of 11,888 residents of a retirement community near Los Angeles, California. After 2 1/2 years of follow-up, 445 incident cancers occurred in 435 of the study participants. Overall, the relative risk of cancer for supplement users versus nonusers was 1.0. In a subset of 32 randomly selected individuals, the 14 supplement users had a significantly higher mean serum retinol level (86 micrograms/dl) than did the 18 nonusers (74 micrograms/dl).

Assessment of three brief methods of estimation of vitamin A and C intakes for a prospective study of cancer: comparison with dietary history.

Three methods of estimating vitamin A and C intakes from food frequency data obtained in June 1981 were compared with estimates obtained from dietary histories taken in September 1982, in 50 elderly residents of a Southern California retirement community. The first method of estimating vitamin A and C intakes (Af and Cf) was to add the products of the frequency of use of foods and the vitamin content of an average serving. The second method of estimating the intakes of these vitamins (Ai and Ci) was to develop an index based on the sum of frequencies of consumption of foods rich in these vitamins. This was then converted to absolute amounts using a regression equation. The third method (Ar and Cr) was to use stepwise multiple regression with the estimated intakes from the history (Ah and Ch) as dependent variables and to develop an equation with a small number of foods as the independent variables. When intakes from food alone were examined, the Spearman correlations between Ah and Af, Ai, and Ar, respectively, were 0.03, 0.16, and 0.43; the correlations between Ch and Cf, Ci, and Cr were 0.29, 0.36, and 0.38. When supplemental vitamin intakes were included, the correlations were between 0.35 and 0.44 for vitamin A and between 0.62 and 0.64 for vitamin C. The results demonstrated the importance of including the contribution of supplemental vitamins in estimating total vitamin A and C intake and suggested that the index and regression approaches may be superior to Af and Cf for estimating dietary vitamin intakes from food frequency questionnaires.

Dietary intake and nutrient supplement use in a Southern California retirement community.

Dietary histories and information concerning the use of nutritional supplements were obtained from 51 randomly selected residents of an Orange County, CA, retirement community. The nutrients for which dietary intakes were most apt to fall below 100% of the 1980 Recommended Dietary Allowance were: calcium, in both sexes; energy, in males; and iron, thiamin, riboflavin, and niacin in females. With the exception of calcium, few subjects had intakes below two-thirds of the Recommended Dietary Allowances. These findings are similar to those reported in previous dietary surveys of the elderly. Vitamin and mineral supplements were consumed by 72% of the subjects; such consumption was unrelated to dietary intake. Supplemental vitamin C was consumed by 67% of the subjects in amounts ranging from 30 to 5200 mg daily; supplemental vitamin E was taken by 51%, with amounts ranging from 8 to 1000 IU daily. Supplement use by this population is one of the highest reported among the elderly, an effect that may result from the affluence of the community, its geographic location, and from a high level of nutritional consciousness among its residents.

Bladder cancer etiology. A different perspective.

The descriptive epidemiologic features of bladder cancer and lung cancer in Los Angeles County were studied for the period 1972-1976, using data from the Los Angeles County/University of Southern California Cancer Surveillance Program. The incidence pattern for bladder cancer was found to differ markedly from the pattern observed for lung cancer. As expected, the descriptive pattern for lung cancer closely paralleled the known epidemiology of cigarette smoking; in addition, it was consistent with the expected pattern of an occupationally linked disease. In contrast, the pattern observed for bladder cancer indicated that factors other than cigarette smoking and occupational exposures may be etiologically important. The available descriptive epidemiology of coffee consumption, unlike that of cigarette smoking, is consistent with the pattern of bladder cancer occurrence in Los Angeles. Available analytic studies on the association of bladder cancer and coffee consumption are consistent with a causal relationship.