Mediterranean diet and hip fracture incidence among older adults: the CHANCES project.

The association between adherence to Mediterranean diet (MD) and hip fracture incidence is not yet established. In a diverse population of elderly, increased adherence to MD was associated with lower hip fracture incidence. Except preventing major chronic diseases, adhering to MD might have additional benefits in lowering hip fracture risk. INTRODUCTION: Hip fractures constitute a major public health problem among older adults. Latest evidence links adherence to Mediterranean diet (MD) with reduced hip fracture risk, but still more research is needed to elucidate this relationship. The potential association of adherence to MD with hip fracture incidence was explored among older adults. METHODS: A total of 140,775 adults (116,176 women, 24,599 men) 60 years and older, from five cohorts from Europe and the USA, were followed-up for 1,896,219 person-years experiencing 5454 hip fractures. Diet was assessed at baseline by validated, cohort-specific, food-frequency questionnaires, and hip fractures were ascertained through patient registers or telephone interviews/questionnaires. Adherence to MD was evaluated by a scoring system on a 10-point scale modified to be applied also to non-Mediterranean populations. In order to evaluate the association between MD and hip fracture incidence, cohort-specific hazard ratios (HR), adjusted for potential confounders, were estimated using Cox proportional-hazards regression and pooled estimates were subsequently derived implementing random-effects meta-analysis. RESULTS: A two-point increase in the score was associated with a significant 4% decrease in hip fracture risk (pooled adjusted HR 0.96; 95% confidence interval (95% CI) 0.92-0.99, pheterogeneity = 0.446). In categorical analyses, hip fracture risk was lower among men and women with moderate (HR 0.93; 95% CI 0.87-0.99) and high (HR 0.94; 95% CI 0.87-1.01) adherence to the score compared with those with low adherence. CONCLUSIONS: In this large sample of older adults from Europe and the USA, increased adherence to MD was associated with lower hip fracture incidence.

Milk and other dairy foods and risk of hip fracture in men and women.

The role of dairy foods for hip fracture prevention remains controversial. In this study, among US men and women, a glass of milk per day was associated with an 8% lower risk of hip fracture. This contrasts with a reported increased risk with higher milk intake in Swedish women. INTRODUCTION: The purpose of this study was to examine whether higher milk and dairy food consumption are associated with risk of hip fracture in older adults following a report of an increased risk for milk in Swedish women. METHODS: In two US cohorts, 80,600 postmenopausal women and 43,306 men over 50 years of age were followed for up to 32 years. Cox proportional hazards models were used to calculate the relative risks (RR) of hip fracture per daily serving of milk (240 mL) and other dairy foods that were assessed every 4 years, controlling for other dietary intakes, BMI, height, smoking, activity, medications, and disease diagnoses. RESULTS: Two thousand one hundred thirty-eight incident hip fractures were identified in women and 694 in men. Each serving of milk per day was associated with a significant 8% lower risk of hip fracture in men and women combined (RR = 0.92, 95% confidence interval (CI) 0.87 to 0.97). A suggestive inverse association was found for cheese in women only (RR = 0.91, CI 0.81 to 1.02). Yogurt consumption was low and not associated with risk. Total dairy food intake, of which milk contributed about half, was associated with a significant 6% lower risk of hip fracture per daily serving in men and women (RR = 0.94, CI 0.90 to 0.98). Calcium, vitamin D, and protein from non-dairy sources did not modify the association between milk and hip fracture, nor was it explained by contributions of these nutrients from milk. CONCLUSIONS: In this group of older US adults, higher milk consumption was associated with a lower risk of hip fracture.

Multivitamin use and risk of stroke incidence and mortality amongst women.

BACKGROUND AND PURPOSE: Few studies have examined the association between multivitamin use and the risk of stroke incidence and mortality, and the results remain inconclusive as to whether multivitamins are beneficial. METHODS: The associations between multivitamin use and the risk of incident stroke and stroke mortality were prospectively examined in 86 142 women in the Nurses' Health Study, aged 34-59 years and free of diagnosed cardiovascular disease at baseline. Multivitamin use and covariates were updated every 2 years and strokes were documented by review of medical records. Hazard ratios of total, ischaemic and hemorrhagic strokes were calculated across categories of multivitamin use (non-user, past, current user) and duration (years), using Cox proportional hazards models. RESULTS: During 32 years of follow-up from 1980 to 2012, 3615 incident strokes were documented, including 758 deaths from stroke. In multivariate analyses, women who were current multivitamin users did not have a lower risk of incident total stroke compared to non-users [relative risk (RR) 1.02, 95% confidence interval (CI) 0.93-1.11], even those with longer durations of 15 or more years of use (RR 1.08, 95% CI 0.97-1.20) or those with a lower quality diet (RR 0.96, 95% CI 0.80-1.15). There was also no indication of benefit from multivitamin use for incident ischaemic or hemorrhagic strokes or for total stroke mortality. CONCLUSIONS: Long-term multivitamin use was not associated with reduced risk of stroke incidence or mortality amongst women in the study population, even amongst those with a lower diet quality. An effect in a less well-nourished population cannot be ruled out.

Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project.

BACKGROUND: Hip fractures are associated with diminished quality of life and survival especially amongst the elderly. OBJECTIVE: All-cause mortality after hip fracture was investigated to assess its magnitude. METHODS: A total of 122 808 participants from eight cohorts in Europe and the USA were followed up for a mean of 12.6 years, accumulating 4273 incident hip fractures and 27 999 deaths. Incident hip fractures were assessed through telephone interviews/questionnaires or national inpatient/fracture registries, and causes of death were verified with death certificates. Cox proportional hazards models and the time-dependent variable methodology were used to assess the association between hip fracture and mortality and its magnitude at different time intervals after the injury in each cohort. We obtained the effect estimates through a random-effects meta-analysis. RESULTS: Hip fracture was positively associated with increased all-cause mortality; the hazard ratio (HR) in the fully adjusted model was 2.12, 95% confidence interval (CI) 1.76-2.57, after adjusting for potential confounders. This association was stronger amongst men [HR: 2.39, 95% CI: 1.72-3.31] than amongst women [HR: 1.92, 95% CI: 1.54-2.39], although this difference was not significant. Mortality was higher during the first year after the hip fracture [HR: 2.78, 95% CI: 2.12-3.64], but it remained elevated without major fluctuations after longer time since hip fracture [HR (95% CI): 1.89 (1.50-2.37) after 1-4 years; 2.15 (1.81-2.55) after 4-8 years; 1.79 (1.57-2.05) after 8 or more years]. CONCLUSION: In this large population-based sample of older persons across eight cohorts, hip fracture was associated with excess short- and long-term all-cause mortality in both sexes.

Protein intake and risk of hip fractures in postmenopausal women and men age 50 and older.

In this study, we followed postmenopausal women and men aged 50 and above for up to 32 years and found no evidence that higher protein intake increased the risk of hip fracture. Protein intake from specific sources was inversely associated with risk, but these associations appeared to differ by gender. INTRODUCTION: We examined the association between intakes of total and specific sources of protein and hip fracture risk in postmenopausal women and men over 50 years of age. Our hypothesis was that a higher protein intake would not be associated with a higher risk of hip fractures. METHODS: In this analysis, we followed 74,443 women in the Nurses' Health Study between 1980 and 2012 and 35,439 men from the Health Professionals Follow-up Study between 1986 and 2012. Health and lifestyle information and hip fractures were self-reported on biennial questionnaires. Protein was assessed approximately every 4 years with a food frequency questionnaire. Relative risks (RR) were computed for hip fracture by quintiles of total, animal, dairy, and plant protein intakes using Cox proportional hazard models, adjusting for potential confounders. RESULTS: During follow-up, we ascertained 2156 incident hip fractures in women and 595 fractures in men. Among men, we observed significant inverse associations for each 10 g increase of total protein (RR = 0.92, 95% CI = 0.85-0.99) and animal protein (RR = 0.91, 95% CI = 0.85-0.98) intakes. Total and animal proteins were not significantly associated with hip fractures in women. Both plant (RR = 0.88, 95% CI 0.79-0.99 per 10 g) and dairy protein (RR = 0.92, 95% CI 0.86-0.97) were associated with significantly lower risks of hip fracture when results for men and women were combined. None of these associations were modified by BMI, smoking, physical activity, age, or calcium intake. CONCLUSION: We found no evidence that higher protein intake increases risk of hip fracture in these Caucasian men and women. Protein intake from specific sources was inversely associated with risk, but these associations appeared to differ by gender.

Abdominal obesity and hip fracture: results from the Nurses' Health Study and the Health Professionals Follow-up Study.

UNLABELLED: Abdominal obesity might increase fracture risk. We studied the prospective associations between waist circumference, waist-to-hip ratio, and hip fracture. The indicators of abdominal obesity were associated with increased hip fracture risk in women, but not in men. The increased risk was restricted to women with low physical activity. INTRODUCTION: Low weight is an established risk factor for osteoporosis and hip fracture. However, the association between fat tissue, muscle, and bone is complex, and abdominal obesity might increase fracture risk. We studied the prospective associations between indicators of abdominal obesity and hip fracture in two large US cohorts. METHODS: At baseline in 1986 and through biennial follow-up, information on hip fracture and potential risk factors was collected in 61,677 postmenopausal women and 35,488 men above age 50. Waist and hip circumferences were reported at baseline and updated twice. RESULTS: During follow-up, 1168 women and 483 men sustained a hip fracture. After controlling for known risk factors, there was a significant association in women between increasing waist circumference and hip fracture (RR per 10-cm increase 1.13 (95 % CI 1.04-1.23) and between increasing waist-to-hip ratio and hip fracture (RR per 0.1 unit increase 1.14 (95 % CI 1.04-1.23), but these associations were not seen in men. In women, both measures interacted with physical activity. Those in the highest (≥0.90) versus lowest (<0.75) category of waist-to-hip ratio had increased risk of hip fracture if their activity was less than the population median (RR = 1.61, 95 % CI 1.18-2.19) but not if their activity was higher (RR = 1.00, 95 % CI 0.72-1.40). A similar pattern was found for waist circumference. CONCLUSION: Indicators of abdominal obesity were associated with increased hip fracture risk after controlling for BMI in women. The increased risk was restricted to women with low physical activity. In men, no significant associations were found.

Education, marital status, and risk of hip fractures in older men and women: the CHANCES project.

UNLABELLED: The role of socioeconomic status in hip fracture incidence is unclear. In a diverse population of elderly, higher education was found to be associated with lower, whereas living alone, compared to being married/cohabiting, with higher hip fracture risk. Educational level and marital status may contribute to hip fracture risk. INTRODUCTION: The evidence on the association between socioeconomic status and hip fracture incidence is limited and inconsistent. We investigated the potential association of education and marital status with hip fracture incidence in older individuals from Europe and USA. METHODS: A total of 155,940 participants (79 % women) aged 60 years and older from seven cohorts were followed up accumulating 6456 incident hip fractures. Information on education and marital status was harmonized across cohorts. Hip fractures were ascertained through telephone interviews/questionnaires or through record linkage with registries. Associations were assessed through Cox proportional hazard regression adjusting for several factors. Summary estimates were derived using random effects models. RESULTS: Individuals with higher education, compared to those with low education, had lower hip fracture risk [hazard ratio (HR) = 0.84, 95 % confidence interval (CI) 0.72-0.95]. Respective HRs were 0.97 (95 % CI 0.82-1.13) for men and 0.75 (95 % CI 0.65-0.85) for women. Overall, individuals living alone, especially those aged 60-69 years, compared to those being married/cohabiting, tended to have a higher hip fracture risk (HR = 1.12, 95 % CI 1.02-1.22). There was no suggestion for heterogeneity across cohorts (P heterogeneity > 0.05). CONCLUSIONS: The combined data from >150,000 individuals 60 years and older suggest that higher education may contribute to lower hip fracture risk. Furthermore, this risk may be higher among individuals living alone, especially among the age group 60-69 years, when compared to those being married/cohabiting.

Dietary patterns and risk of hip fractures in postmenopausal women and men over 50 years.

UNLABELLED: We followed 74,540 postmenopausal women and 35,451 men above age 50 for up to 30 years. Neither the prudent pattern, characterized by higher intakes of whole grains, fruits, and vegetables, nor the Western pattern, characterized by higher intakes of red/processed meats, and refined grains were associated with hip fracture risk. INTRODUCTION: We examined the association between predominant dietary patterns and risk of hip fractures in postmenopausal women and men over 50 years. METHODS: We used data from 74,540 women in the Nurses' Health Study followed between 1980 and 2010, and 35,451 men from the Health Professionals Follow-up Study followed between 1986 and 2012 for this analysis. Health and lifestyle information was assessed every 2 years. Diet was assessed approximately every 4 years with a food frequency questionnaire. Two major dietary patterns were previously derived using principal component analysis. The prudent pattern is characterized by higher intakes of fruits, vegetables, whole grains, and poultry, and the Western pattern is characterized by higher intakes of red and processed meats, sweets, and refined grains. We computed relative risks (RR) for hip fracture by dietary pattern scores using Cox proportional hazards models, adjusting for potential confounders. RESULTS: During follow-up, there were 1891 hip fractures in women and 596 in men. No association was observed between the prudent or Western pattern and risk of hip fractures in either men or women. We also did not find an association among lean (body mass index (BMI) <25) or overweight (BMI ≥25) individuals or among those with higher or lower levels of physical activity. CONCLUSION: Neither the prudent nor the Western dietary pattern was associated with risk of hip fractures in postmenopausal women or men over 50 years of age.

Non-steroidal anti-inflammatory drugs, acetaminophen, and risk of skin cancer in the Nurses' Health Study.

PURPOSE: Non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with lower risk of certain cancers, but data on the effect on skin cancer risk have been limited and contradictory. We prospectively examined whether use of NSAIDS or acetaminophen was associated with a lower risk of skin cancer in women. METHODS: The 92,125 Caucasian women in the Nurses' Health Study provided information on aspirin use in 1980. Other NSAIDs and acetaminophen were added in 1990. Medication use, frequency, and quantity were reassessed on biennial questionnaires. Through 2008, we confirmed 658 melanoma cases, 1,337 squamous cell carcinoma (SCC) cases, and had 15,079 self-reports of basal cell carcinoma (BCC). We used COX proportional hazards models to compute relative risks (RR) adjusted for known skin cancer risk factors. RESULTS: Neither aspirin nor non-aspirin NSAID use was associated with a lower risk of melanoma, SCC, or BCC, even for women with high quantity, frequency, or duration of use. Instead, we observed an increased risk of melanoma among current aspirin users (RR = 1.32, 95 % CI 1.03-1.70), though an increase of similar magnitude among past users and lack of a dose-response effect did not support a pharmacologic mechanism. We observed a mild reduction in SCC risk in current acetaminophen users (RR = 0.88, 95 % CI 0.75-1.02), with a linear decrease in risk with greater frequency of use (p = 0.04). CONCLUSIONS: Aspirin and other NSAIDs were not associated with a lower risk of melanoma, SCC, or BCC in women. Our large, prospective study does not support a chemoprotective effect of NSAIDs against skin cancers.

Dietary intake of polyunsaturated fatty acids and risk of hip fracture in men and women.

UNLABELLED: Data on the impact of polyunsaturated fatty acid intake on hip fracture risk are inconsistent. We investigated this association in 75,878 women and 46,476 men and did not find a significant role for polyunsaturated fatty acid intake in the prevention of hip fractures. INTRODUCTION: Polyunsaturated fatty acids (PUFA) are important in the prevention of chronic diseases, but studies of bone health report inconsistent results. Our aim was to investigate the association between dietary PUFA intake and risk of hip fracture in two large prospective cohorts of men and women with long follow-up times and frequently updated dietary data. METHODS: The study population included 75,878 women and 46,476 men free of osteoporosis at baseline. Dietary intakes were assessed by a food frequency questionnaire at baseline and several times during the follow-up. Multivariable-adjusted Cox proportional hazards models were used to estimate relative risks (RR). RESULTS: During 24 years of follow-up, we identified 1,051 hip fracture cases due to low or moderate trauma among the women and 529 cases among the men. In the pooled analyses, no statistically significant associations were found between intakes of total PUFA [RR in the highest vs. lowest quintile: 0.99, 95% confidence interval (CI) 0.69, 1.43; p value for trend is =0.83], total n-3 PUFA (RR 0.89, 95% CI 0.75, 1.06; p value for trend is =0.26), total n-6 PUFA (RR 0.99, 95% CI 0.71, 1.38; p value for trend is =0.82), n-6/n-3 PUFA ratio or individual PUFAs, and hip fracture risk. However, in women low intakes of total PUFA, total n-6 PUFA, and linoleic acid were associated with higher risk. CONCLUSIONS: This study does not support a significant role for PUFA intake in the prevention of hip fractures, although low total PUFA, n-6 PUFA, or linoleic acid intakes may increase the risk in women.

Physical activity patterns and prevention of weight gain in premenopausal women.

BACKGROUND: Studies of the association between physical activity (PA) and weight maintenance have been inconsistent. METHODS: We prospectively examined the association between PA patterns and prevention of weight gain among 46 754 healthy premenopausal women, aged 25-43 years in 1989. Participants reported their PA and weight in 1989 and 1997. The primary outcome was gaining >5% of baseline weight by 1997 (62% of the population). RESULTS: Compared with women who maintained <30 min d(-1) of total discretionary activity over 8 years, women were less likely to gain weight if they sustained 30+ min d(-1) (odds ratio (OR)=0.68, 95% confidence interval (CI) 0.64-0.73) or increased to 30+ min d(-1) in 1997 (OR=0.64, 95%CI=0.60-0.68). Among women whose only reported activity was walking, risk of gaining weight was lower in those who sustained 30+ min d(-1) over 8 years (OR=0.66, 95%CI=0.49-0.91), and brisk walking pace independently predicted less weight gain. For a 30 min d(-1) increase between 1989 and 1997, jogging/running was associated with less weight gain than brisk walking or other activities. Greater duration of PA was associated with progressively less weight gain, but even an 11-20 min d(-1) increase was beneficial; the benefits appeared stronger among those who were initially overweight. Sedentary behavior independently predicted weight gain. CONCLUSIONS: Sustained PA for at least 30 min d(-1), particularly if more intense, is associated with a reduction in long-term weight gain, and greater duration is associated with less weight gain. Sedentary women of any baseline weight who increase their PA will benefit, but overweight women appear to benefit the most.

Nightshift work and fracture risk: the Nurses' Health Study.

SUMMARY: Nightshift work suppresses melatonin production and has been associated with an increased risk of major diseases including hormonally related tumors. Experimental evidence suggests that light at night acts through endocrine disruption likely mediated by melatonin. To date, no observational study has addressed the effect of night work on osteoporotic fractures, another condition highly sensitive to sex steroid exposure. Our study, to our knowledge, the first to address this question, supports the hypothesis that nightshift work may negatively affect bone health, adding to the growing list of ailments that have been associated with shift work. INTRODUCTION: We evaluated the association between nightshift work and fractures at the hip and wrist in postmenopausal nurses. METHODS: The study population was drawn from Nurses' Health Study participants who were working full or part time in nursing in 1988 and had reported their total number of years of rotating nightshift work. Through 2000, 1,223 incident wrist and hip fractures involving low or moderate trauma were identified among 38,062 postmenopausal women. We calculated multivariate relative risks (RR) of fracture over varying lengths of follow-up in relation to years of nightshift work. RESULTS: Compared with women who never worked night shifts, 20+ years of nightshift work was associated with a significantly increased risk of wrist and hip fractures over 8 years of follow-up [RR = 1.37, 95% confidence interval (CI), 1.04-1.80]. This risk was strongest among women with a lower body mass index (<24) who never used hormone replacement therapy (RR = 2.36; 95% CI, 1.33-4.20). The elevated risk was no longer apparent with 12 years of follow-up after the baseline single assessment of nightshift work. CONCLUSIONS: Long durations of rotating nightshift work may contribute to risk of hip and wrist fractures, although the potential for unexplained confounding cannot be ruled out.

Vitamin D intake and risks of systemic lupus erythematosus and rheumatoid arthritis in women.

OBJECTIVES: Vitamin D has immune-modulating effects and may protect against the development of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). METHODS: We identified incident cases of SLE and RA among 186 389 women followed from 1980 to 2002 in the Nurses' Health Study and Nurses' Health Study II cohorts. We excluded subjects where SLE or RA was not confirmed by medical record review, and those who failed to return questionnaires. Semi-quantitative food frequency questionnaires assessed vitamin D intake from food and supplements. We used cumulative-updated total energy-adjusted dietary exposures for each 2-year cycle. Relationships between vitamin D intake and incident SLE and RA were examined in age-adjusted and Cox proportional hazards models, adjusted for confounders. Results were pooled using meta-analysis random effects models. RESULTS: We confirmed 190 incident cases of SLE and 722 of RA with dietary information. Increasing levels of vitamin D intake had no relationship to the relative risk of developing either SLE or RA. CONCLUSIONS: Vitamin D intake was not associated with risk of SLE or RA in these large prospective cohorts of women.

Aspirin and lung cancer risk in a cohort study of women: dosage, duration and latency.

Aspirin may reduce the risk of cancer at some sites but its effect at the lung is unclear. We prospectively examined associations between aspirin use and risk of lung cancer in 109,348 women in the Nurses' Health study from 1980 to 2004. During this time, 1,360 lung cancers were documented in participants 36-82 years of age. Aspirin use and smoking were assessed every 2 years. Risk of lung cancer was a non-significant 16% lower for regular aspirin users of one or two tablets per week and a significant 55% higher for users of 15 or more tablets per week compared with women who never regularly used aspirin. Results were similar when limited to never smokers. For both the low and high quantity aspirin users, risk of lung cancer did not decline or increase with longer durations of use, and associations attenuated as the latency period between aspirin assessment and lung cancer diagnosis was lengthened. Our findings, together with those from previous clinical trials and prospective studies, do not provide consistent evidence that aspirin influences the development of lung cancer and further investigation is required with adjustment for smoking.

Physical activity and risk of breast cancer in premenopausal women.

Physical activity appears to be inversely related to risk of breast cancer, yet the results remain inconsistent. To evaluate this relation among premenopausal women and examine variation in risk according to level of obesity and use of oral contraceptives (OCs), the authors examined data from the Nurses' Health Study II. During 10 years of follow-up, 849 cases of invasive premenopausal breast cancer were confirmed. Physical activity was assessed by self-report at baseline and during follow-up using a validated questionnaire. Total physical activity was unrelated to risk of breast cancer. Women engaging in >or=27 metabolic equivalent (MET)-h week(-1) had a multivariate-adjusted relative risk (RR) of 1.04 (95% confidence interval (CI) 0.82-1.33) compared to those in the <3 MET-h week(-1) category. Among women with a BMI >or=30 kg m(-2), we observed a significant positive dose-response relation (P=0.04). Activity was unrelated to breast cancer risk at lower levels of BMI. A test for interaction between activity and BMI (<30, >or=30 kg m(-2)) was statistically significant (P=0.02). Among current OC users, higher activity was associated with a non-significantly lower risk of breast cancer (RR=0.59, 95% CI 0.30-1.16 for >or=27 vs <9 MET-h week(-1), P for linear trend=0.14). These results show no overall association between physical activity and risk of breast cancer among premenopausal women, but suggest that the effect of physical activity could be substantially modified by the underlying degree of adiposity. The potential interactions between physical activity, adiposity, and current use of OCs require further study.

Dietary intakes of vitamins A, C, and E and risk of melanoma in two cohorts of women.

Within the two Nurses' Health Study cohorts of US women, we examined whether higher intakes of vitamin C, vitamin E, retinol, or individual tocopherols or carotenoids are associated with a lower risk of melanoma. We confirmed 414 cases of invasive melanoma among over 162,000 Caucasian women aged 25-77 years during more than 1.6 million person-years of follow-up. Diet was measured every 4 years with a food frequency questionnaire and supplement use was reported every 2 years. Several measures of sun sensitivity were assessed and included in proportional hazards models. We found that vitamins A, C, E and their individual components were not associated with a lower risk of melanoma. Only retinol intake from foods plus supplements appeared protective within a subgroup of women who were otherwise at low risk based on nondietary factors (relative risk (RR)=0.39, 95% confidence interval (CI) 0.22-0.71 for >/=1,800 vs 400 microg day(-1), P for linear trend=0.01). Contrary to expectation, we observed higher risks of melanoma with greater intakes of vitamin C from food only (RR=1.43, 95% CI 1.01-2.00 for >/=175 vs <90 mg day(-1), P for linear trend=0.05) and a significant positive dose-response with frequency of orange juice consumption (P=0.008). Further research is needed to determine whether another component in foods such as orange juice may contribute to an increase in risk.

Stress and suicide in the Nurses' Health Study.

STUDY OBJECTIVES: Although stress is thought to be a risk factor for suicide, most research has been retrospective or has focused on attempted suicides or suicide ideation. This study examined prospectively the associations between self perceived stress, diazepam use, and death from suicide among adult women. DESIGN: A cohort study was conducted with 14 years of follow up. Stress at home and at work were assessed by questionnaire and scored on a four point scale: minimal, light, moderate, or severe. SETTING: Eleven states within the United States. PARTICIPANTS: Female nurses (n=94 110) who were 36 to 61 years of age when they answered questions on stress and diazepam use in 1982. RESULTS: During 1 272 000 person years of observation 73 suicides were identified. After adjustment for age, smoking, coffee consumption, alcohol intake, and marital status, the relation between self reported stress and suicide remained U shaped. Compared with the light home and work stress categories, which had the lowest incidences of suicide, risks were increased among women reporting either severe (relative risk (RR) = 3.7, 95% confidence intervals (CI) 1.7 to 8.3) or minimal (RR=2.1, 95% CI 1.0 to 4.5) home stress and either severe (RR=1.9, 95% CI 0.8 to 4.7) or minimal (RR=2.4, 95% CI 0.9 to 6.1) work stress. When responses to home and work stress were combined, there was an almost fivefold increase in risk of suicide among women in the high stress category. Risk of suicide was over eightfold among women reporting high stress or diazepam use compared with those reporting low stress and no diazepam use. CONCLUSIONS: The relation between self reported stress and suicide seems to be U shaped among adult women. The excess risk for those reporting minimal stress may reflect denial or undiagnosed depression or an association with some other unmeasured risk factor for suicide.

Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in women.

BACKGROUND: Little is known about the overall health effects of adherence to the Dietary Guidelines for Americans. The healthy eating index (HEI), developed at the US Department of Agriculture, measures how well Americans' diets conform to these guidelines. OBJECTIVE: We tested whether the HEI (scores range from 0 to 100; 100 is best) calculated from food-frequency questionnaires (HEI-f) would predict risk of major chronic disease in women. DESIGN: A total of 67272 US female nurses who were free of major disease completed detailed questionnaires on diet and chronic disease risk factors in 1984 and repeatedly over 12 y. Major chronic disease was defined as fatal or nonfatal cardiovascular disease (myocardial infarction or stroke, n = 1365), fatal or nonfatal cancer (n = 5216), or other nontraumatic deaths (n = 496), whichever came first. We also examined cardiovascular disease and cancer as separate outcomes. RESULTS: After adjustment for smoking and other risk factors, the HEI-f score was not associated with risk of overall major chronic disease in women [relative risk (RR) = 0.97; 95% CI: 0.89, 1.06 comparing the highest with the lowest quintile of HEI-f score]. Being in the highest HEI-f quintile was associated with a 14% reduction in cardiovascular disease risk (RR = 0.86; 95% CI: 0.72, 1. 03) and was not associated with lower cancer risk (RR = 1.02; 95% CI: 0.93, 1.12). CONCLUSION: These data suggest that adherence to the 1995 Dietary Guidelines for Americans, as measured by the HEI-f, will have limited benefit in preventing major chronic disease in women.

Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in men.

BACKGROUND: The Dietary Guidelines for Americans and the food guide pyramid aim to reduce the risk of major chronic disease in the United States, but data supporting their overall effectiveness are sparse. The healthy eating index (HEI) measures the concordance of dietary patterns with these guidelines. OBJECTIVE: We tested whether a high HEI score (range: 0-100; 100 is best) calculated from a validated food-frequency questionnaire (HEI-f) could predict lower risk of major chronic disease in men. DESIGN: A cohort of US male health professionals without major disease completed detailed questionnaires on food intake and other risk factors for heart disease and cancer in 1986 and repeatedly during the 8-y follow-up. Major chronic disease outcome was defined as incident major cardiovascular disease (stroke or myocardial infarction, n = 1092), cancer (n = 1661), or other non-trauma-related deaths (n = 366). RESULTS: The HEI-f was weakly inversely associated with risk of major chronic disease [comparing highest with lowest quintile of the HEI-f, relative risk (RR) = 0.89; 95% CI: 0.79, 1.00; P: < 0.001 for trend]. The HEI-f was associated with moderately lower risk of cardiovascular disease (RR = 0.72; 95% CI: 0.60, 0.88; P: < 0.001) but was not associated with lower cancer risk. CONCLUSIONS: The HEI-f was only weakly associated with risk of major chronic disease, suggesting that improvements to the HEI may be warranted. Further research on the HEI could have implications for refinements to the Dietary Guidelines for Americans and the food guide pyramid.

Prospective study of fruit and vegetable consumption and risk of lung cancer among men and women.

BACKGROUND: Diets high in fruits and vegetables have been shown to be associated with a lower risk of lung cancer. beta-Carotene was hypothesized to be largely responsible for the apparent protective effect, but this hypothesis was not supported by clinical trials. METHODS: We examined the association between lung cancer risk and fruit and vegetable consumption in 77 283 women in the Nurses' Health Study and 47 778 men in the Health Professionals' Follow-up Study. Diet was assessed with the use of a food-frequency questionnaire that included 15 fruits and 23 vegetables. We used logistic regression models to estimate relative risks (RRs) of lung cancer within each cohort. All statistical tests were two-sided. RESULTS: We documented 519 lung cancer cases among the women and 274 among the men. Total fruit and vegetable consumption was associated with a modestly lower risk of lung cancer among the women but not among the men. The RR for the highest versus lowest quintile of intake was 0.79 (95% confidence interval [CI] = 0.59-1.06) among the women and 1.12 (95% CI = 0.74-1.69) among the men after adjustment for smoking status, quantity of cigarettes smoked per day, time since quitting smoking, and age at initiation of smoking. However, total fruit and vegetable consumption was associated with a lower risk of lung cancer among never smokers in the combined cohorts, although the reduction was not statistically significant (RR = 0.63; 95% CI = 0.35-1.12 in the highest tertile). CONCLUSION: Higher fruit and vegetable intakes were associated with lower risks of lung cancer in women but not in men. It is possible that the inverse association among the women remained confounded by unmeasured smoking characteristics, although fruits and vegetables were protective in both men and women who never smoked.