Nonfasting plasma total homocysteine level and mortality in middle-aged and elderly men and women in Jerusalem.

BACKGROUND: Elevated plasma total homocysteine level has been associated with cardiovascular disease in many studies, mostly in Europe and North America. Data on persons from other areas and on associations with overall mortality are sparse. OBJECTIVE: To determine the relation of plasma homocysteine level to all-cause and cause-specific mortality. DESIGN: Prospective observational study with 9- to 11-year follow-up. SETTING: A free-living, multiethnic Jewish population in western Jerusalem, Israel. PARTICIPANTS: 1788 residents of Jerusalem (808 men and 980 women) who were at least 50 years of age and were examined between 1985 and 1987 as part of the Kiryat Yovel Community Health Study. MEASUREMENTS: Nonfasting plasma homocysteine level was determined in frozen stored samples. Deaths during follow-up were identified by linkage with the national population registry. RESULTS: Plasma homocysteine levels exceeded 14 micromol/L in 28% of men and 20% of women. During the study period, 405 deaths occurred. In multivariate Cox models that controlled for possible confounders, a nonmonotonic increase in mortality hazard ratios was associated with ascending quintile of homocysteine level: 1.0, 1.4, 1.3, 1.5, and 2.0 (P < 0.001 for trend). The relation was similar for cardiovascular and noncardiovascular causes of death (excluding cancer). The association was weaker when deaths that occurred during the first 5 years of follow-up were excluded; corresponding hazard ratios for ascending quintile of homocysteine level were 1.0, 1.0, 1.2, 1.1, and 1.6 (P = 0.063 for trend). Age- and sex-adjusted percentages of deaths "attributable" to elevated plasma homocysteine level (> or = 14 micromol/L) were 12.5% (95% CI, 6.7% to 18.8%) for all deaths, 16.0% (CI, 7.2% to 25.6%) for deaths during the first 5 years of follow-up, and 8.3% (CI, 1.5% to 16.1%) for later deaths. CONCLUSIONS: A mildly to moderately elevated nonfasting plasma homocysteine level is a substantial risk marker for death from all causes. The association seems to be stronger during the first 5 years of follow-up.

The prevalence of obesity and its changes over time in middle-aged and elderly men and women in Jerusalem.

OBJECTIVE: To study the prevalence and correlates of overweight and obesity in Jerusalem, and changes over a 15-17 year period. DESIGN: Two cross-sectional surveys in 1970 and in 1986, among residents aged 50 years and more in a defined neighbourhood. SUBJECTS: The study samples comprised 1267 individuals in 1970 and 1858 in 1986. RESULTS: In 1986, 33% of women and 16% of men were obese (BMI > or = 30.0 kg/m2). There was a decreasing trend in the prevalence of obesity with age among women, and in men there was no overall trend but the lowest prevalence was in the 75-84 age-group. Significant relationships with education and region of birth were observed in women only. Prevalence was lowest in the more educated and in women born in Europe and America. Subjects' self-appraisal and their report of physicians' diagnosis of health disorders, revealed a significantly higher prevalence of ill-health among obese people. In 1986 the mean body mass index and the prevalence of obesity were higher than in 1970, in both sexes and in almost all age groups. The prevalence rate of obesity (standardized by sex and age) was 21% in 1970 and 25% in 1986, the difference was statistically significant (p = 0.008). The age standardized prevalence rate in each sex was also higher in 1986 although statistically significant only in men (p = 0.037). CONCLUSION: A community study in Jerusalem revealed a high prevalence of overweight and obesity in 1986 in this middle-aged and elderly population; and a higher mean body mass index and an increased prevalence of obesity were found in 1986 than in 1970, in both sexes. The increased prevalence of obesity among men could not be explained by changes in the age, education and ethnic composition of the population. Among women, the possibility cannot be excluded that part of the increase in obesity was attributable to changes in the distribution of the population by region of birth.

Trends in blood pressure levels over time in middle-aged and elderly Jerusalem residents.

Change in blood pressure levels over time was investigated in Jerusalem, in two cross-sectional surveys in 1970 and in 1986 among residents of a neighbourhood aged 50 years and more. The study population comprised 1397 individuals in 1970 and 1858 in the 1986. Age-adjusted mean systolic and diastolic blood pressure levels were lower in 1986 than in 1970 by 6.9 mmHg and 4.7 mmHg, respectively. The prevalence of blood pressure levels above 160 and/or 95 mmHg in 1986 was lower by 50% and there was a twofold increase in current treatment for hypertension. The reduction in blood pressure in both sexes remained evident upon control for confounding effects of age, ethnic group, education, body mass index and reported treatment for hypertension. The proportion of people who had blood pressure levels below 140/90 and did not report being under treatment, increased. The possibility of methodological problems inherent in this type of study were considered. More effective antihypertensive treatment in 1986 can explain only part of the reduction. The decrease in levels of blood pressure as revealed by this study may reflect a real reduction in the population that could explain part of the striking decline in cardiovascular mortality in Israel.

Evaluation of a community-oriented primary care workshop for family practice residents in Jerusalem.

BACKGROUND: A workshop on community-oriented primary care (COPC) has been integrated into Hebrew University's family practice residency program for several years. The participants of the first three workshops did an evaluation to assess subsequent application of the COPC approach. METHODS: The main objectives of the 45-hour workshop are: a) to learn the principles and practice of COPC as illustrated by the Hadassah Community Health Center programs, and b) to learn skills required in the COPC programs' various stages of development. In the workshop, physicians are required to work in groups of 5-6 to carry out the planning of COPC programs, which will be implemented in their practices. A structured questionnaire was sent 2-4 years after workshop completion to each of the 45 physicians who participated in these workshops. RESULTS: Thirty-six of the 45 physicians responded to the questionnaire. Of the 36 respondents, 75% reported that the content of the workshop was relevant to their daily work. Eighty percent of the physicians who were involved in intervention programs reported that participation in the workshop improved their ability to plan community programs. Fifty-five percent of the respondents reported the application of elements learned in the workshop to their current work, mainly in the performance of three COPC functions: definition of the community, identification of health problems, and planning community health interventions. Few (28%) were involved in evaluation measurements. CONCLUSIONS: A COPC workshop characterized by work groups of family physicians, epidemiological analysis of their practices' data, and the planning of a community program in their communities was positively evaluated according to the reported application of COPC functions by family physicians and residents in their daily work.

Obstructive prostatic symptoms: a community survey in Jerusalem.

BACKGROUND: Benign prostatic hypertrophy has a high prevalence in men aged > or = 50, but there is little information on the correlates of obstructive symptoms. METHODS: The prevalence and correlates of reported prostatic symptoms in men aged > or = 50 years were studied in a community survey in the Kiryat Hayovel neighbourhood of Jerusalem in 1985-1987. Five prostate-related questions were asked. Two indices of emotional health were used: the Psychiatric Epidemiology Research Interview demoralization scale and a scale based on the Cornell Medical Index. Associations with sociodemographic, behavioural, emotional, biochemical and physical variables and with self-appraised health were examined both controlling for age only and by multivariate logistic regression. RESULTS: The prevalence rates in the 839 respondents were 20.4% for hesitancy, 41.1% for weak stream, and 26.7% for terminal dribbling; the rates tended to increase with age. The associations between the symptoms (controlling for age) were significant, the strongest being between hesitancy and weak stream. All three of the urinary symptoms were associated with indices of emotional distress. In the multivariate analysis, the odds ratios when men in the highest and lowest quartiles of emotional ill health were compared were 3.0 for hesitancy, 2.2 for weak stream, and 3.8 for dribbling. Specific symptoms were associated with blood pressure, social class and educational level. CONCLUSION: The striking associations with emotional ill health underline the importance of appropriate attention to the emotional health of patients who complain of prostatic symptoms.

Work satisfaction and health in the middle-aged and elderly.

BACKGROUND: There is evidence that occupational factors that cause psychological strain can affect physical and mental health, but findings are not consistent. METHODS: Work satisfaction was used as a convenient global index of job-related psychological strain. Relationships with general, physical and emotional health, appraised by the use of questions, were examined in workers aged > or = 50 years in a longitudinal community health study in Jerusalem. RESULTS: Positive associations were found both in 1975-1976 and in 1985-1987, with age, origin, education, sex and other variables controlled. The odds ratio in favour of poor general health was 2.8 times as high in dissatisfied workers as in very satisfied ones. Multivariate analyses suggested that the associations were not spurious ones attributable to a proneness to report both dissatisfaction and ill-health. Workers who expressed dissatisfaction in both 1975-1976 and 1985-1987 were particularly unhealthy in 1985-1987. CONCLUSIONS: The findings support the impact of work satisfaction or its determinants on current health, and suggest that persistent dissatisfaction may be especially deleterious to health.

The CHAD program for the control of cardiovascular risk factors in a Jerusalem community: a 24-year retrospect.

The CHAD program, a community health program for the control of cardiovascular risk factors, was planned in 1969 as an experiment in community-oriented primary care (COPC) with the aim of assessing feasibility and effectiveness. The program was instituted in a family practice in Jerusalem in 1970, and has provided a working demonstration of the integration of community health care with the care of individuals and families. Effectiveness was evaluated by comparing changes in risk factor status with those in a comparison population. The program was most effective with respect to the control of hypertension and cigarette smoking. The changes were larger and earlier than those in the comparison population. Positive changes were also observed in the comparison population, which was served by a primary care clinic that also undertook measures for the control of cardiovascular risk factors.

A simplified index of physical health for use in epidemiological studies.

A battery of simple questions designed to measure physical health, in terms of ability to perform physical activities, was appraised in 1839 men and women aged greater than or equal to 50 years in a community survey in Jerusalem. The number of "Yes" answers to six questions, five of which could be skipped if the first one was answered positively, was found to be a satisfactory index, with a high degree of consistency-reliability in the total sample (Cronbach's alpha coefficient = 0.97) and in subgroups categorized by sex, age, education, or father's region of birth. The index constituted an excellent Guttman scale (coefficient of reproducibility = 0.96, coefficient of scalability = 0.94), indicating that the score serves both as a measure of physical health and as an indication of the profile of capabilities. Associations with age and other variables conformed with expectations, attesting the construct validity of the index.

Work-health relationships in middle-aged and elderly residents of a Jerusalem community.

Work-health relationships were examined cross-sectionally in 1886 men and women aged greater than or equal to 50 years in Jerusalem in 1985-1987, in the third round of a multipurpose longitudinal community health study. The main occupational variables were employment status, reasons for not working, and satisfaction with work. Sex and age were controlled in all comparisons. Workers were clearly healthier than nonworkers with respect to general, physical and emotional health, and people who had given up work were less healthy than those still working, whether they had stopped for health reasons, only because of their age, or only for extrinsic reasons (retrenchment or dismissal). Workers who expressed satisfaction with their work were healthier than others, the odds ratio in favour of good general health being 2.4 at 50-64 and 2.5 at greater than or equal to 65 years of age. The associations between job satisfaction and health remained apparent when education and origin were controlled. Multivariate analyses suggested that the associations were not spurious ones attributable to proneness to report both dissatisfaction and ill-health. Job dissatisfaction was not significantly associated with angina pectoris, possible myocardial infarction, or hypertension. Taken at their face value, the findings support the impact of job satisfaction or its determinants on the health of middle-aged and elderly men and women. The associations will be re-appraised in the longitudinal analysis of the study data.

[A smoking cessation program for pregnant women: minimal input intervention].

A prevalence study of smoking during pregnancy showed that 30% of women in the Jerusalem area were smokers at the beginning of pregnancy and that 67% of women who quit smoking during an earlier pregnancy had started again after delivery. An organized series of health promotion activities for smokers was therefore begun in the framework of routine prenatal care at 4 MCH clinics in Jerusalem. This minimal input smoking cessation program was based on 4 elements: motivation, information, behavioral changes and reinforcement. In face-to-face contact the nurses provided relevant information and recommended specific methods for quitting, based on the reported reasons for smoking. The high prevalence among pregnant women of husbands who had ever smoked suggested their involvement in the program and support to change this harmful behavior. A simple recording system was developed to maintain surveillance of smoking habits and to monitor the planned activities. Controlled evaluation procedures based on the measurement of changes of smoking habits and knowledge and attitudes towards smoking during pregnancy, will test whether this program is feasible for spreading the health promotion message to the family as a whole. Preliminary results point to a positive influence of the intervention population.

[Intervention technics in the community: community diagnosis]. / Técnicas de intervención en comunidad: el diagnóstico comunitario.

The practice of community mental health care demands the introduction of suitable models of intervention. Community medicine, which has preceded the development of community mental health, offers operative models based on epidemiologic concepts and techniques. This paper analyses the different components of community diagnosis, a necessary step in the process of community intervention. A practical example illustrates the use of the latter by the mental health worker.

Técnicas de intervención en comunidad: el diagnóstico comunitario / The process of community intervention: a community diagnosis

En este trabajo se analizan los propósitos y componentes del diagnóstico comunitario en salud mental usando los modelos epidemiológicos desarrollados por la medicina comunitaria. El diagnóstico comunitario constituye el paso principal en la toma de decisiones racionale para la intervención en comunidad. Un ejemplo práctico ilustra el proceso de su realización y aplicación en un programa asistencial

Técnicas de intervención en comunidad: el diagnóstico comunitario / The process of community intervention: a community diagnosis

En este trabajo se analizan los propósitos y componentes del diagnóstico comunitario en salud mental usando los modelos epidemiológicos desarrollados por la medicina comunitaria. El diagnóstico comunitario constituye el paso principal en la toma de decisiones racionale para la intervención en comunidad. Un ejemplo práctico ilustra el proceso de su realización y aplicación en un programa asistencial (AU0

Técnicas de intervención en comunidad: el diagnóstico comunitario. / [Intervention technics in the community: community diagnosis]

The practice of community mental health care demands the introduction of suitable models of intervention. Community medicine, which has preceded the development of community mental health, offers operative models based on epidemiologic concepts and techniques. This paper analyses the different components of community diagnosis, a necessary step in the process of community intervention. A practical example illustrates the use of the latter by the mental health worker.

Ten-year evaluation of hypertension, overweight, cholesterol, and smoking control: the CHAD program in Jerusalem. Community Syndrome of Hypertension, Atherosclerosis and Diabetes.

Control of hypertension, overweight, hypercholesterolemia, and smoking is a major objective of the CHAD program, a multifactorial cardiovascular risk factor program built into a family practice, which has operated in a neighborhood of western Jerusalem since 1971. By 1975-1976, there was a significantly larger decrease in risk factors in this population than in a neighboring population receiving ordinary medical care. Follow-up based on clinical records of a cohort of 441 people exposed to the program until 1981 revealed that the mean blood pressures decreased and the prevalence of hypertension continued to decrease between 1976 and 1981, from 12.5 to 9.1%. Prevalence of cigarette smoking among people ages 30 years or more also decreased in this period, mainly due to a decrease in heavy smoking, at a time when national surveys provided no evidence of a smoking decrease in this age group. Effects on overweight and cholesterol were not demonstrated during this period. This 10-year evaluation demonstrates the effects of intervention by primary care practitioners in the framework of a community-oriented program.

Cigarette smoking and its relation to anthropometric characteristics and biochemical variables in Jerusalem 17-year-olds and adults.

The relationship of weight, height, Quetelet index, hematocrit and blood levels of thyroxine, globulin, bilirubin, creatinine, aspartate aminotransferase, uric acid, alkaline phosphatase and glucose to smoking was studied in a Jerusalem population sample of youngsters aged 17 yr and their parents. Among youngsters, male smokers had a higher body mass index than did male nonsmokers. In adults, both men and women smokers were slightly leaner than ex-smokers and, in women, smokers were clearly leaner than those who had never smoked. Generally, the associations of smoking with the biochemical variables were weaker in youngsters than in adults. In men, lower mean levels of creatinine, bilirubin, aspartate aminotransferase and uric acid were observed among smokers. Hematocrit levels were somewhat higher in both young and adult smokers of both sexes, being more so in adults. Smokers showed consistently lower globulin levels than did nonsmokers. Plasma glucose levels were somewhat lower in youngsters of both sexes who smoked. Serum thyroxine levels were slightly increased in female smokers, suggesting a hormonal effect of smoking. These findings are discussed in light of the published literature.

Clustering of chronic disorders--a community study of coprevalence in Jerusalem.

Associations between chronic disorders were appraised in a community survey in western Jerusalem in order to identify clusters of mutually related conditions. Two sets of interrelated diseases were observed. The first comprised coronary heart disease, hypertension, diabetes and their complications. The second included migraine and other chronic disorders whose diagnosis was largely based on subjective symptoms. The presence of these complaint-based disorders was associated with a high prevalence of emotional symptoms, with reported difficulties in the life situation, and with frequent doctor visits. The design of appropriate programs of preventive and therapeutic intervention for this cluster of disorders remains an important challenge.