Alcohol consumption and risk of ischemic heart disease in women.

BACKGROUND: Most studies suggest that alcohol use decreases the risk of coronary heart disease in men, however, this association has not been well established in women. METHOD: This study investigates the relationship between alcohol use and ischemic heart disease (IHD) incidence among women aged 45 to 74 years in the Epidemiologic Follow-up Study of the First National Health and Nutrition Examination Survey. The cohort was free of heart disease at baseline. During the follow-up period (mean, 13 years), 884 IHD cases were identified through hospital records, reported hospital stays, or death certificates. RESULTS: Women reporting any amount of alcohol use had about a 20% decrease in risk of IHD incidence compared with abstainers. Using a Cox regression model to adjust for known cardiovascular risk factors, this relative risk of IHD remained essentially unchanged. The greatest reduction in the risk of IHD (36% to 39%) was among women who consumed about half to two drinks per day compared with abstainers. CONCLUSIONS: This study of a nationally representative sample with a mean follow-up of 13 years and a substantial number of IHD cases suggests that moderate alcohol use decreases the risk of IHD. However, the risk and benefits of moderate alcohol consumption need to be viewed within a broader perspective especially since the potentially harmful effects of alcohol have been well documented.

Weight change between age 50 years and old age is associated with risk of hip fracture in white women aged 67 years and older.

BACKGROUND: Although changes in body weight with aging are common, little is known about the effects of weight change on health in old age. OBJECTIVES: To study the effects of weight loss and weight gain from age 50 years to old age on the risk of hip fracture among postmenopausal white women aged 67 years and older and to determine if the level of weight at age 50 years modifies this risk. METHODS: The association between weight change and the risk of hip fracture was studied in 3683 community-dwelling white women aged 67 years and older from three sites of the Established Populations for Epidemiologic Studies of the Elderly. RESULTS: Extreme weight loss (10% or more) beginning at age 50 years was associated in a proportional hazards model with increased risk of hip fracture (relative risk [RR], 2.9; 95% confidence interval [CI], 2.0-4.1). This risk was greatest among women in the lowest (RR, 2.3; CI, 1.1-4.8) and middle (RR, 2.8; CI, 1.5-5.3) tertiles of body mass index at age 50 years. Among the thinnest women, even more modest weight loss (5% to < 10%) was associated with increased risk of hip fracture (RR, 2.3; CI, 1.0-5.2). Weight gain of 10% or more beginning at age 50 years provided borderline protection against the risk of hip fracture (RR, 0.7; CI, 0.4-1.0). The RRs for weight gain of 10% or more were protective only among women in the middle and high tertiles of body mass index at age 50 years and were not significant (middle tertile RR, 0.8; CI, 0.3-1.8; high tertile RR, 0.6; CI, 0.2-1.9). CONCLUSIONS: Weight history is an important determinant of the risk of hip fracture. Weight loss beginning at age 50 years increases the risk of hip fracture in older white women, especially among those who are thin at age 50 years; weight gain of 10% or more decreases the risk of hip fracture. Physicians should include weight history in their assessment of postmenopausal older women for risk of hip fracture.

The relationship between fish consumption and stroke incidence. The NHANES I Epidemiologic Follow-up Study (National Health and Nutrition Examination Survey).

OBJECTIVE: To assess the level of fish consumption as a risk factor fo r stroke. METHODS: Participants were members of the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study, a longitudinal cohort study of a national sample. Included in this analysis were white and black women and men aged 45 to 74 years when examined in 1971 through 1975 who did not report a history of stroke at that time. Average follow-up for survivors was 12 years (maximum, 16 years). The main outcome measure was incident stroke (fatal and nonfatal). Fish consumption at baseline was obtained from a 3-month food frequency questionnaire. RESULTS: White women aged 45 to 74 years who consumed fish more than once a week had an age-adjusted risk of stroke incidence only about half that of women who never consumed fish. This effect persisted after controlling for multiple stroke risk variables (relative risk, 0.55;95% confidence interval [CI], 0.32 to 0.93). Fish consumption more than once a week compared with never was not associated with age-adjusted stroke risk in white men aged 45 to 74 years (relative risk, 0.85;95%CI,0.49 to 1.46). In black women and men combined aged 45 to 74 years, any fish consumption compared with never was significantly associated with reduced adjusted stroke risk (relative risk, 0.51;95%CI,0.30 to 0.88).

Decreased risk of stroke among postmenopausal hormone users. Results from a national cohort.

OBJECTIVE: To assess the impact of postmenopausal hormone use on the risk of stroke incidence and stroke mortality. DESIGN: Longitudinal study consisting of three data collection waves. The average follow up for cohort members was 11.9 years (maximum, 16.3 years). Cox proportional hazards regression models were used to estimate the relative risk of stroke for postmenopausal hormone ever-users compared with never-users. PARTICIPANTS: A national sample of 1910 (of 2371 eligible) white postmenopausal women who were 55 to 74 years old when examined in 1971 through 1975 as part of the first National Health and Nutrition Examination Survey and who did not report a history of stroke at that time. MAIN OUTCOME MEASURE: The main outcome measure was incident stroke (fatal and nonfatal). Events were determined from discharge diagnosis information coded from hospital and nursing home records and cause of death information coded from death certificates collected during the follow-up period (1971 through 1987). RESULTS: There were 250 incident cases of stroke identified, including 64 deaths with stroke listed as the underlying cause. The age-adjusted incidence rate of stroke among postmenopausal hormone ever-users was 82 per 10,000 woman-years of follow-up compared with 124 per 10,000 among never-users. Postmenopausal hormone use remained a protective factor against stroke incidence (relative risk, 0.69; 95% confidence interval, 0.47 to 1.00) and stroke mortality (relative risk, 0.37; 95% confidence interval, 0.14 to 0.92) after adjusting for the baseline risk factors of age, systolic blood pressure, diabetes, body mass index, smoking, history of hypertension and heart attack, and socioeconomic status. CONCLUSIONS: The results suggest that postmenopausal hormone use is associated with a decrease in risk of stroke incidence and mortality in white postmenopausal women.

Serum folate and cardiovascular disease mortality among US men and women.

BACKGROUND: Folate has been linked to cardiovascular disease (CVD) through its role in homocysteine metabolism. OBJECTIVE: To assess the relationship between serum folate and CVD mortality. DESIGN: In this prospective study, serum folate concentrations were measured on a subset of adults during the Second National Health and Nutrition Examination Survey (1976-1980) and vital status ascertained after 12 to 16 years. SETTING AND PATIENTS: A national probability sample consisting of 689 adults who were 30 to 75 years of age and did not have a history of CVD at baseline. MAIN OUTCOME MEASURE: Vital status was determined by searching national databases that contained information about US decedents. RESULTS: The associations between serum folate and CVD and all-cause mortality differed by diabetes status (P =.04 and P =.03, respectively). Participants without diabetes in the lowest compared with the highest serum folate tertile had more than twice the risk of CVD mortality after adjustment for age and sex (relative risk [RR], 2.64; 95% confidence interval [CI], 1.15-6.09). This increased risk for participants in the lowest tertile was attenuated after adjustment for CVD risk factors (RR, 2.28; 95% CI, 0.96-5.40). Serum folate tertiles were not significantly associated with total mortality, although the age- and sex-adjusted risk was increased for participants in the lowest compared with highest tertile (RR, 1.74; 95% CI, 0.96-3.15). Risk estimates for participants with diabetes were unstable because of the small sample size (n = 52). CONCLUSION: These data suggest that low serum folate concentrations are associated with an increased risk of CVD mortality among adults who do not have diabetes. Arch Intern Med. 2000;160:3258-3262.

Self-perceived stress and the risk of peptic ulcer disease. A longitudinal study of US adults.

BACKGROUND: Although many physicians and laypersons believe that stress plays a role in the occurrence of peptic ulcer disease, the importance of stress in the pathogenesis of peptic ulcers remains controversial. METHODS: To investigate the relationship between perceived stress and peptic ulcer disease we used data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study--a nationally representative cohort study of US adults. This analysis included 4511 persons who had not previously been diagnosed with peptic ulcer disease. RESULTS: At baseline, 68% of the cohort perceived themselves as stressed. During 13 years of follow-up, 208 persons developed ulcers; the cumulative incidence of ulcers was 7.2% for persons who were stressed and 4.0% for persons who were not. After we adjusted for age, sex, education, smoking status, and regular aspirin use, persons who perceived themselves as stressed were 1.8 times more likely to develop ulcers than those who did not (95% confidence interval, 1.3 to 2.5). We also found a graded relationship between the perceived amount of stress and the incidence of peptic ulcers; relative to nonstressed persons, the relative risk of developing an ulcer was 1.4, 1.9, 2.3, 2.4, and 2.9 at five increasing levels of stress. CONCLUSIONS: These findings suggest that persons who perceive their lives as stressful may be at increased risk for the development of peptic ulcer disease.

Phalangeal bone density and hip fracture risk.

OBJECTIVE: To assess the long-term predictive usefulness of radiographic absorptiometry measurements of phalangeal bone density for hip fracture risk. METHODS: Participants were members of the First National Health and Nutrition Examination Survey Epidemiologic Follow Up Study cohort. Subjects were followed up for a maximum of 16 years. The First National Health and Nutrition Examination Survey data were obtained from a nationally representative sample of non-institutionalized civilians. A cohort of 3481 white and black subjects (1559 white women) aged 45 through 74 years at baseline (1971-1975) were observed through 1987. Ninety-eight percent of the original cohort completed the study. Hospital records and death certificates were used to identify a total of 72 hip fracture cases. Phalangeal bone density at baseline was measured using photodensitometry (PD), and later reanalyzed by radiographic absorptiometry (RA), a newer, more sophisticated technique. RESULTS: Results were evaluated to determine the relative risk for hip fracture per 1-SD decrease in bone density, after controlling for age at baseline, race, gender, weight, and previous fractures. Both RA and PD measurements showed a significant inverse relationship to hip fracture risk, with RA density measurements showing a slightly higher adjusted relative risk per 1-SD density decrease than PD measurements. For RA bone density, the relative risk for all subjects was 1.81 (95% confidence interval, 1.34-2.44) compared with 1.57 (95% confidence interval, 1.19-2.07) for PD bone density after adjusting for age at baseline, race, gender, weight, and previous fractures. Results for white women were essentially the same as those for all subjects for RA bone density and PD bone density. CONCLUSIONS: Phalangeal bone density determined from standard hand x-ray films is a significant predictor of future hip fracture risk. Availability of a valid method to assess fracture risk using conventional radiographs will expand the ability to identify individuals with osteoporosis.

Risk factors for hip fracture in white men: the NHANES I Epidemiologic Follow-up Study.

This prospective population-based study assessed predictors of hip fracture risk in white men. Participants were members of the Epidemiologic Follow-up Study cohort of the First National Health and Nutrition Examination Survey, a nationally representative sample of noninstitutionalized civilians who were followed for a maximum of 22 years. A cohort of 2879 white men (2249 in the nutrition and weight-loss subsample, 1437 in the bone density subsample) aged 45-74 years at baseline (1971-1975) were observed through 1992. Ninety-four percent of the original cohort were successfully traced. Hospital records and death certificates were used to identify a total of 71 hip fracture cases (61 in the nutrition and weight-loss subsample, 26 in the bone-density subsample). Among the factors evaluated were age at baseline, previous fractures other than hip, body mass index, smoking status, alcohol consumption, nonrecreational physical activity, weight loss from maximum, calcium intake, number of calories, protein consumption, chronic disease prevalence, and phalangeal bone density. The risk adjusted relative risk (RR) of hip fracture was significantly associated with presence of one or more chronic conditions (RR = 1.91, 95% confidence interval [CI] = 1.19-3.06), weight loss from maximum > or = 10% (RR = 2.27, 95% CI 1.13-4.59), and 1 SD change in phalangeal bone density (RR = 1.73, 95% CI 1.11-2.68). No other variables were significantly related to hip fracture risk. Although based on a small number of cases, this is one of the first prospective studies to relate weight loss and bone density to hip fracture risk in men.

A method to redefine stays on the 1985 National Nursing Home Survey.

This report describes a method for standardizing definitions of episodes of nursing home care in the 1985 National Nursing Home Survey. The method shows how the information on nursing home admissions and discharges collected on the Current and Discharged Resident Questionnaires can be used to redefine the endpoints of nursing home stays. The report also explains how errors caused by missing and inconsistent nursing home admission and discharge data were resolved.

Electrocardiographic estimate of left ventricular mass versus radiographic cardiac size and the risk of cardiovascular disease mortality in the epidemiologic follow-up study of the First National Health and Nutrition Examination Survey.

The prognostic value of a left ventricular (LV) mass index (g/m2) estimated from an electrocardiographic model and radiographic estimates of the relative heart volume (ml/m2) and cardiothoracic ratio for predicting the risk of cardiovascular disease mortality were investigated using Cox regression analysis to adjust for age, systolic blood pressure and history of heart attack in 1,807 men (1,609 white, 198 black) and 2,143 women (1,884 white, 259 black). The study population (ages 35 to 74 years at baseline) was followed from 5 to 12 years (average 9.5 years) for cardiovascular disease mortality. LV mass index and relative heart volume were independent predictors of cardiovascular disease mortality among white men. All 3 cardiac size estimates were independent predictors for cardiovascular disease mortality among white and black women. When LV mass index was used as a dichotomized variable to indicate the presence or absence of LV hypertrophy, the age-adjusted relative risk of cardiovascular disease mortality was 2.48 (95% confidence interval 1.77 to 3.46) for white men, 3.03 (1.49 to 6.16) for black men, 1.86 (1.21 to 2.87) for white women and 2.05 (0.83 to 5.05) for black women. The corresponding prevalence of LV hypertrophy was 15.4% for white men, 36.6% for black men, 20.1% for white women and 17.4% for black women. It is concluded that the electrocardiographic estimate of LV mass index can identify a substantially larger fraction of persons at increased risk for cardiovascular mortality than conventional electrocardiographic criteria for LV hypertrophy and that LV mass index estimated by electrocardiogram is a valuable supplement to radiographic cardiac size estimates in epidemiologic applications.

Long-term survival after coronary heart disease. Comparisons between men and women in a national sample.

This study examined the sex differential in long-term survival after incident coronary heart disease (CHD) in the Epidemiologic Followup Study to the First National Health and Nutrition Examination Survey. This cohort was first contacted in 1971 to 1975 with follow-up through 1987. Of the 1407 white participants for whom CHD was identified at some point during the study, 56% of men and 46% of women died during the follow-up period. After adjustment for age at incidence, traditional heart disease risk factors, and initial coronary disease diagnosis, the relative risk of death among women compared to men was 0.70. Women's survival advantage after myocardial infarction was 0.81. Women who had ever taken post-menopausal estrogens were most likely to survive after CHD or myocardial infarction compared to men (relative risks [RRs] = 0.42 and 0.57, respectively), although women who did not take estrogen were also significantly more likely than men to survive after CHD (RR = 0.79) but not after myocardial infarction (RR = 0.88).

Modification of the relationship between the Quetelet index and mortality by weight-loss history among older women.

The effect of weight on mortality was examined using data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study for white women aged 65 to 74 years at baseline. There was a U-shaped curve relating the Quetelet index categories to total mortality, with increased risk for both lean and heavy women. However, the increased risk to lean subjects occurred only among those who had lost more than 8.55% from their reported lifetime maximum weight. Controlling for baseline medical conditions, excluding early years of follow-up, and limiting the analysis to never-smokers did not greatly change the results. Lean women with stable weight have the lowest risk of mortality, while those who have lost weight have a high risk. Heavy women have a high risk of mortality regardless of weight-loss history. Thus, the effect of weight on mortality is modified by history of weight loss in older women, even when accounting for factors associated with weight loss and increased mortality risk.

Regional variation in ischemic heart disease incidence.

This study examines the relationship between cardiovascular risk factors and regional variation in IHD incidence among white males 55-74 years of age from the NHANES I Epidemiologic Followup Study. The age-adjusted IHD incidence rate was lowest in the west (31.3 per 1000 persons years of followup). The rates in the northeast, midwest, and south were similar and so they were combined into one region, the non-west, with a rate of 42.4. Differences in risk factors (smoking, educational level, hypertension, serum cholesterol, diabetes mellitus, and body mass index) did not explain the regional differences in IHD incidence. After adjusting for baseline risk factors using proportional hazards model, the risk of IHD incidence was still 38% higher in the non-west compared to the west. However, the effect of hypertension, diabetes, and body mass index on IHD incidence varied by region.

The relation between fish consumption, death from all causes, and incidence of coronary heart disease. the NHANES I Epidemiologic Follow-up Study.

1 time/week (adjusted relative risk 0.85, 95% CI 0.68-1.06). Similar but nonsignificant trends were seen in white and black women, but not black men. In white men, risk of noncardiovascular death but not cardiovascular death was also significantly reduced in those consuming fish once or more a week. No consistent association of fish consumption and coronary heart disease incidence or mortality was seen. White men consuming fish once a week had significantly lower risk of death over a 22-year follow-up than those never consuming fish. This was mostly attributable to reductions in death from noncardiovascular causes. Similar patterns, though not significant, were seen in women. Further studies are needed to confirm these findings and to elucidate mechanisms for the effect of fish consumption on noncardiovascular mortality.

Diabetes mellitus, coronary heart disease incidence, and death from all causes in African American and European American women: The NHANES I epidemiologic follow-up study.

Few data are available on risk for coronary heart disease in African American women with diabetes mellitus, a well-established coronary risk factor in European American women. This study tests the hypothesis that medical history of diabetes predicts coronary heart disease incidence in African American women in a national cohort. Participants in the NHANES I Epidemiologic Follow-up Study in this analysis were 1035 African American and 5732 European American women aged 25-74 years without a history of coronary heart disease. Average follow-up for survivors was 19 years (maximum 22 years). Risk of incident coronary heart disease by baseline diabetes status was estimated. Proportional hazards analyses for African American women aged 25-74 revealed significant associations of coronary heart disease risk with diabetes after adjusting for age (RR = 2.40; 95% CI, 1.58-3.64, P < 0.01). After adjusting for age, smoking, and low education, there was an elevated risk in diabetics age 25-74 (RR = 2. 34; 95% CI, 1.54-3.56, P < 0.01); this association did not differ significantly from that for European American women. Excess coronary incidence in African American compared to European American women aged 25-64 was statistically explained by controlling for diabetes history, age, education, and smoking but only partly explained by age and diabetes history. In African American women aged 25-74, diabetes was also associated with increased coronary heart disease, cardiovascular, and all-cause mortality. The population attributable risk of coronary heart disease incidence associated with a medical history of diabetes was 8.7% in African American women and 6.1% in European American women. Medical history of diabetes was a significant predictor of coronary heart disease incidence and mortality in African American women and explained some of the excess coronary incidence in younger African American compared to European American women.

Anthropometric indicators and hip fracture. The NHANES I epidemiologic follow-up study.

A cohort of 3,595 white women aged 40-77 years was followed for an average of 10 years during which 84 new cases of hip fracture were identified. Triceps skinfold thickness and arm muscle area measured at baseline were examined as possible risk factors for hip fracture controlling for physical activity, height, menopausal status, calcium consumption, and smoking. Of these variables only arm muscle area, triceps skinfold thickness, and activity in recreation were independent predictors of hip fracture incidence using the Cox proportional hazards model. After adjustment, the estimated relative risk of hip fracture was approximately two for an increment of each anthropometric indicator (adjusted for the other) equivalent to comparing those at the 25th percentile to those at the 75th percentile (maximum width of 95% confidence intervals, 1.2-2.9). Risk of hip fracture was approximately two-fold for persons who reported little recreational exercise compared to persons who reported much recreational exercise (95% confidence interval, 1.2-3.2). Our findings are the first evidence from a prospective study that anthropometric indicators besides body mass index may have an independent relationship to risk of hip fracture.

Greater collaboration across the disciplines: challenges and opportunities.

This paper reports a panel discussion--Opportunities for and Limitations to Greater Collaboration Across the Disciplines--held at the conference. It highlights the need for greater collaboration between demographers and epidemiologists and notes the institutional and disciplinary challenges to and opportunities for promoting greater cooperation.

Social class and risk factors for coronary heart disease in the Federal Republic of Germany. Results of the baseline survey of the German Cardiovascular Prevention Study (GCP).

The relationship between social class and seven important risk factors for coronary heart disease has been evaluated utilising data from the German Cardiovascular Prevention Study baseline survey. Of German residents aged 25 to 69 years, 16,430 were randomly selected from both the six intervention regions and the Federal Republic of Germany to undergo the screening procedures between 1984 and 1986. Among males the prevalence of cigarette smoking and lack of physical activity was associated with social class. For females, overweight and physical activity demonstrated a strong social gradient. No relationship existed between social class and hypercholesterolaemia. The prevalence of Type A behaviour was significantly higher for the upper social classes. The number of CHD risk factors per study subject increased with decreasing social class. Predicted cardiovascular mortality was clearly higher for the lower social class among males in general and for females younger than 60 years. These findings point to the need for risk factor intervention strategies focusing more on the lower social classes in order to achieve more adequate prevention of coronary heart disease.

10 years after NHANES I: report of initial followup, 1982-84.

The NHANES I Epidemiologic Followup Study (NHEFS) was jointly initiated by the National Center for Health Statistics and the National Institute on Aging in collaboration with other National Institutes of Health and Public Health Service agencies. The goal of NHEFS is to examine the relationship of baseline clinical, nutritional, and behavioral factors assessed in the first National Health and Nutrition Examination Survey (NHANES I-1971-75) to subsequent morbidity and mortality. Data collection for the initial phase of followup took place between 1982 and 1984 and included tracing of all NHANES I participants, determining their vital status, conducting in-depth interviews with surviving participants or with proxies for those who were deceased or incapacitated, conducting selected physical measurements, obtaining facility records for stays in hospitals or nursing homes that occurred during the period of followup, and obtaining death certificates for decedents. Ninety-three percent of the original cohort was successfully traced. Interviews were conducted for 93 percent of traced, surviving participants and 84 percent of traced, surviving participants and 84 percent of traced, deceased subjects. Physical measurements were obtained for approximately 95 percent of surviving, interviewed subjects. Death certificates are available for more than 95 percent of the decedents, and 18,136 facility records were received for 6,477 subjects.

10 years after NHANES I: mortality experience at initial followup, 1982-84.

The NHANES I Epidemiologic Followup Study (NHEFS) was initiated jointly by the National Center for Health Statistics and the National Institute on Aging in collaboration with other National Institutes of Health and Public Health Service agencies. The goal of NHEFS is to examine the relationship of baseline clinical, nutritional, and behavioral factors assessed in the first National Health and Nutrition Examination Survey (NHANES I-1971-75) to subsequent morbidity and mortality. Tracing for the initial followup began in 1981 and ended in 1984. This article compares the mortality experience of the NHEFS cohort with survival probabilities and cause-of-death distributions derived from U.S. vital statistics data. The analysis was done for 28 age-race-sex specific subgroups. The survival of each group of the NHEFS cohort corresponds quite closely to that expected on the basis of the U.S. life table survival probabilities. Mortality differentials by age, race, and sex are also quite similar between NHEFS and U.S. vital statistics. In addition, the cause-of-death distributions among NHEFS participants are quite similar to those expected based on national vital statistics. Thus, there do not seem to be any serious biases in the mortality data. The NHEFS, therefore, provides a unique resource for assessing the effects of baseline sociodemographic, health, and nutritional factors on future mortality in a large, heterogeneous sample that is representative of the nation's population.