Lactose and galactose intake and metabolism in relation to the risk of epithelial ovarian cancer

It has been suggested that aspects of lactose consumption and metabolism favoring a relatively high tissue level of galactose-1-phosphate may predispose women to ovarian cancer. The authors sought to examine this hypothesis in a study of 108 18- to 74-year-old Caucasian residents of a three-county area of western Washington who were diagnosed with stage I ovarian cancer during 1989-1991, and 108 age- and race-matched controls. Lactose and galactose intake, measured using a food frequency questionnaire, had been hypothesized to increase risk, but were somewhat lower among the cases than among the controls (75th percentile of lactose intake vs. 25th: odds ratio (OR) = 0.80, 95% confidence interval (Cl) 0.52-1.2; of galactose intake: OR = 0.71, 95% Cl 0.48-1.1). Intestinal lactase activity, also hypothesized to have a positive relation with ovarian cancer occurrence, was measured with an oral lactose challenge followed by determination of urinary galactose; no evidence that it was related to the disease was found (75th percentile of excreted galactose vs. 25th: OR = 0.87, 95% Cl 0.62-1.2). Galactose-1-phosphate uridyltransferase (transferase), the enzyme responsible for the metabolism of galactose-1-phosphate, was measured in erythrocytes; no deficit in cases was observed (75th percentile of transferase activity vs. 25th: OR = 1.3, 95% Cl 0.80-2.1). There was also no excess of cases carrying low-activity genetic variants of the transferase enzyme (lower-activity variants vs. higher-activity variants: OR = 0.61, 95% Cl 0.21-1.7). These results do not support the hypothesis that aspects of lactose and galactose intake and metabolism have a bearing on the etiology of ovarian cancer.

Interpreting excess mortality in a prevention trial for older adults

BACKGROUND

In a randomized trial evaluating preventive services for older adults excess mortality was observed in the treatment group. We examined four explanations: unbalance of baseline characteristics, unintended effects of the intervention, consequence of an autonomy intervention (including increased number of living wills in the treatment group), and chance. We focus here on the effects of the autonomy intervention.

METHODS

Preparation of living wills in the treatment and control groups was compared both at baseline and follow-up. A linear predictor of mortality was used to identify participants at high risk of dying. Charts of these 200 participants were reviewed for evidence of serious medical events and resuscitation decisions. Rates of life-sustaining treatment were compared between treatment and controls using logistic regression.

RESULTS

More living wills (65%) were noted for the treatment group than control group (47%) at follow-up. Thirty-six per cent of participants were identified as having a serious medical event; of these, participants in the treatment group were over twice as likely not to receive life-sustaining treatment.

CONCLUSIONS

Advance directives contributed to excess deaths, indicating the success of the autonomy intervention.

5 A Day for better health--nine community research projects to increase fruit and vegetable consumption

One of the national objectives in "Healthy People 2000" is for members of the public to increase their consumption of fruits and vegetables to five or more servings daily. The National Cancer Institute (NCI) began a nationwide campaign to achieve this objective in 1991. As part of this campaign, the NCI funded nine research studies in 1993. These projects are implementing and evaluating community-based programs designed to increase fruit and vegetable consumption among different segments of the population in Alabama, Arizona, Georgia, Louisiana, Maryland, Massachusetts, Minnesota, North Carolina, and Washington. The settings for these projects include the Special Supplement Food Program for Women, Infants, and Children (WIC Programs), churches, worksites, and schools. The projects are led by multidisciplinary teams and entail extensive collaboration among academic, governmental, private sector, and voluntary agencies within each State. The projects represent a model public health paradigm for conducting this type of research.

Assessing change in diet-intervention research

In nutrition-intervention research, it is important to consider the sensitivity of dietary assessment instruments to the changes in nutrient intake or dietary behavior under study. This presentation describes a measure called "responsiveness," an index of an instrument's sensitivity to change. Illustrations of this measure are from two randomized dietary-intervention trials that targeted reductions in fat intake: the Women's Health Trial (WHT), a trial to test whether fat reduction would reduce the risk of breast cancer, and the Eating Patterns Study (EPS), a trial to evaluate a self-help booklet to promote dietary change. In the WHT, a 4-d diet record (FDDR) was only slightly more responsive to dietary change than was a food-frequency questionnaire (FFQ). In the EPS, a fat-related diet-habits questionnaire was most responsive, followed by an FDDR and an FFQ. These data suggest that short, inexpensive measures such as FFQs or questionnaires that assess dietary habits can be as responsive as multiple-day diet records. More research is needed on the relative responsiveness of dietary assessment tools. Intervention studies should include at least two types of dietary assessment tools and the relative validity, reliability, and responsiveness of these tools should be reported as part of the study outcome.

Effects of physical activity on health status in older adults. II. Intervention studies

This review has focused on a specific part of the relationship of exercise to health. The overall evidence supporting the health benefits of exercise is substantial and has been critically reviewed recently (18, 94). Thus, the United States Preventive Services Task Force recommends that all adults exercise regularly (94). The conclusions summarized below regarding older adults do not affect this basic recommendation. There is solid evidence that exercise can improve measures of fitness in older adults, particularly strength and aerobic capacity. These exercise effects occur in chronically ill adults, as well as in healthy adults. Because physical fitness is a determinant of functional status, it is logical to ask whether exercise can prevent or improve impairments in functional status in older adults. The evidence that exercise improves functional status is promising, but inconclusive. Problems with existing studies include a lack of randomized controlled trials, a lack of evidence that effects of exercise can be sustained over long periods of time, inadequate statistical power, and failure to target physically unfit individuals. Existing studies suggest that exercise may produce improvements in gait and balance. Arthritis patients may experience long-term functional status benefits from exercise, including improved mobility and decreased pain symptoms. Nonrandomized trials suggest exercise promotes bone mineral density and thereby decreases fracture risk. Recent studies have generally concluded that short-term exercise does not improve cognitive function. Yet the limited statistical power of these studies does not preclude what may be a modest, but functionally meaningful, effect of exercise on cognition. Future research, beyond correcting methodologic deficiencies in existing studies, should systematically study how functional status effects of exercise vary with the type, intensity, and duration of exercise. It should address issues in recruiting functionally impaired older adults into exercise studies, issues in promoting long-term adherence to exercise, and whether the currently low rate of exercise-related injuries in supervised classes can be sustained in more cost-effective interventions that require less supervision.

Evaluation of a self-help dietary intervention in a primary care setting

BACKGROUND

Dietary intervention to reduce fat consumption and increase fiber consumption has been recommended by the National Cancer Institute, but there is little evidence concerning the effectiveness of self-help materials. The purpose of this study was to evaluate such self-help materials, introduced by a nurse in a primary care setting.

METHODS

A randomized controlled trial involving 242 subjects was conducted in two primary care clinics in Chapel Hill, NC, in 1987. Changes in fat and fiber consumption in the intervention and control groups during the 3-month interval between interviews were compared using analysis of covariance.

RESULTS

The estimated reduction in fat was 3.8g larger for the intervention group than for the control group, but the confidence interval included zero. For those individuals who had some responsibility for meal preparation there was a larger difference (-6.9g) in favor of the intervention group, although the difference using calorie-adjusted values was -3.8g with a 95% confidence interval (-7.1, -0.4). The differences for fiber change were smaller.

CONCLUSIONS

We found significant small but consistent differential changes associated with a minimal self-help intervention, but we cannot rule out the possibility of some response bias. Nonetheless, this study demonstrates that the use of self-help materials for dietary change is feasible, and may be effective.

Work-related physical exertion and risk of preterm, low birthweight delivery

Although many women work during pregnancy, the effect of maternal job experience on pregnancy outcome is controversial. We investigated whether work-related physical exertion increases a woman's risk of delivering a preterm, low birthweight infant. We studied 773 employed, pregnant women included in the National Longitudinal Survey of Labor Market Experience, Youth Cohort (NLSY), a nationally representative sample of young adults. Data concerning work status, job title during pregnancy, and other factors affecting the outcome of pregnancy were obtained from the NLSY. Assessment of physical exertion was based on job title, using an established catalogue of occupational characteristics. Women in jobs characterised by high physical exertion experienced a higher rate of preterm, low birthweight delivery, defined as maternal report of delivery more than 3 weeks early and birthweight under 2,500 g (adjusted RR = 5.1, 95% CI = 1.5, 17.7). These findings support a policy of limiting work-related physical exertion during pregnancy.

Pictorially assisted recall of past hormone use in case-control studies

A small telephone interview study to evaluate the use of a pictorial memory aid in the recall of past hormone use was conducted in Chapel Hill, North Carolina, in 1986. The analysis presented here was restricted to postmenopausal women aged 45-74 years who had an intact uterus and who had taken hormone replacement therapy for six months or more. Spontaneous recall was compared with recall in which explicit mention of the use of the display was made. The display more than doubled the number of women who recalled both the name and the dose of their therapy. Studies which use memory aids should include questions to further document the usefulness of such aids.

A review of dietary interventions aimed at controlling hypertension

Before planning programs to change dietary behavior in groups of individuals, evidence about the effectiveness of different interventions is needed. Articles published in the journals indexed by Index Medicus between the years 1975-84 were reviewed for evidence concerning the effectiveness of dietary modification programs in achieving dietary change. All program evaluations published in English and aimed at control of blood pressure levels in adults were eligible for review. Twenty-nine articles relevant to the synthesis contained sufficient information evaluating the contribution of dietary intervention. These 20 studies addressed changes in fat consumption, reduction in salt intake and reduction in calories consumed. The methods of intervention ranged from residential programs, through individual counseling and group discussion involving spouses, to audiovisual tapes. The studies had varying periods of follow-up; among those with one or more years of follow-up, a number of studies were able to demonstrate effectiveness using different outcome measures. For some dietary components, notably changes in fat intake and reduction in salt consumption, it has been possible to identify a minimal effective intervention, such as self-help materials or individual instruction, while changes in calorie intake or weight seem to require group counseling with family member involvement. The findings from this information synthesis should prove useful to those planning dietary interventions.

Cancer mortality and type of water source: findings from a study in the UK

The age-adjusted, sex-specific mortality rates from certain cancers of the digestive system were analysed by type of water source supplied to 238 urban areas in England, Wales and Scotland using weighted multiple regression. Of the types of water source, the per cent supplied from upland rivers best described the pattern in cancer mortality for each cancer site and each sex. After adjustment was made for a number of socioeconomic factors, the regression coefficient for the percentage of upland river supply remained statistically significant only for female stomach cancer and female intestinal cancer. The association with intestinal cancer could equally well be explained by some other factor with a strong north-west/south-east geographical distribution. The association found for female stomach cancer could not be accounted for by a geographical trend, but suggests a small effect, equivalent to a relative risk of only 1.11. This is an unexpected finding and must be considered a hypothesis, to be tested further by studies conducted by other researchers, in different locations, preferably on individuals.

The Edgecombe County High Blood Pressure Control Program: III. Social support, social stressors, and treatment dropout

In a hypertension prevalence survey of a stratified random sample of 1,000 households, 2,030 adults (aged 18 years and over) were interviewed and information on psychosocial variables collected. Among 359 hypertensives, there was a consistent relationship between indicators of difficulty in the social environment and dropout from treatment in women. Compared to those who remained in treatment, women who dropped out can be characterized as having less social support on the job, having less perceived spouse approval (if married), having a lower level of perceived access to supportive resources, and being more likely to report feeling pushed most or all of the time if they are homemakers. Relationships between indicators of social support and dropout from treatment in men were found only with support on the job, and for White men, with perceived friend approval.

Is nitrate in the drinking water associated with the risk of cancer in the urban UK?

Several studies have suggested that nitrate levels in drinking water may be linked with stomach cancer. Recent investigations of this hypothesis in rural areas of the UK, where nitrate levels can be high, have been inconclusive. The present study examined mortality data for the years 1969-1973 in 253 urban areas in relation to treated water nitrate levels. Variations in socioeconomic status and urban area size were taken into account. Drinking water nitrate levels were negatively associated with mortality from stomach cancer even when the analysis was restricted to urban areas with nitrate levels above the EEC guide. There was no evidence of a positive association between nitrate in the drinking water and the risk of stomach cancer in the urban areas of the UK, an important finding for the British water industry.

The Edgecombe County (NC) High Blood Pressure Control Program: II. Barriers to the use of medical care among hypertensives

As the initial step in a five-year project to improve control of high blood pressure in Edgecombe County, North Carolina, a survey was conducted in 1980 to determine the prevalence of hypertension and to identify factors which might constitute barriers to the use of medical care by hypertensives. This report summarizes the findings for the 539 hypertensives identified through the baseline survey. In general, Black hypertensives reported more access problems than Whites. Within race, however, males and females differed very little on selected measures of potential access to medical care. Among women, lower scores on potential access were strongly associated with being untreated, whereas for men, concerns about the safety of anti-hypertensive drug therapy were associated with being unaware. On a summary measure of the actual use of medical care in response to symptoms, both male and female treated hypertensives scored higher than their untreated counterparts. The implications of these and other findings for community-based blood pressure control activities are discussed.

The Edgecombe County High Blood Pressure Control Program: I. Correlates of uncontrolled hypertension at baseline

To guide the planning of a multifacetted hypertension control program in Edgecombe County, North Carolina, a baseline survey of a stratified (by township) random sample of 1,000 households was conducted. All adults (greater than or equal to 18 years) were interviewed and had their blood pressures (BP) measured. Five hundred thirty-nine individuals, 27 per cent of the survey population, had diastolic BP greater than or equal to 90 mm Hg or were receiving anti-hypertensive drug therapy. The 539 hypertensives were divided into seven subgroups reflecting successive stages in the control of hypertension based on the awareness, treatment, and control of their hypertension. Unaware hypertensives were further subdivided into three groups according to the recency of their last BP check, and those aware but untreated were subdivided by whether they had previously received treatment. The seven subgroups of hypertensives were compared, separately for women and men, with respect to sociodemographic characteristics, health behaviors, and health status. In general, the progression from undetected hypertension to treatment and control appeared to be associated with being older, female, and White. This progression was further associated with greater educational levels and higher family incomes among women and increasing self-reported morbidity among men. The implications for intervention of these and other described associations are discussed.

Cancer incidence and reuse of drinking water

Several studies in the United States have shown an association between the use of river water as a drinking source and cancer mortality, especially gastrointestinal and urinary tract cancer. In the United Kingdom, many lowland rivers are used both as a drinking water source and as a means of transporting domestic and industrial wastes to the sea. The contribution of rivers to the drinking water supply of London residents has been increasing gradually over the last 50 years. This study of 14 boroughs in the south London area examines cancer incidence using registry data for the period 1968-1974, to assess possible risks associated with water reuse. Socioeconomic characteristics of the boroughs were obtained from the 1971 census. Positive associations were found between the average percentage of domestic sewage effluent in the water supplied to a borough and the incidence of stomach cancer and of urinary cancer in females. These associations were reduced when social factors and variations in borough size were taken into account. In spite of the interpretational problems common in aggregate studies, this study, when considered with the results of the US studies, provides some consistent epidemiologic evidence of a small health risk associated with the reuse of drinking water. The size of the risk in the United Kingdom needs to be confirmed by a definitive study on individuals.

The relationship between water quality and health in the London area

In a retrospective study of the relationship between reuse of water and hazards to health, the mortality experience from different causes, principally cancer, was examined for 29 boroughs and districts in the London area for the period 1968 to 1974. Information concerning the source of water supply to each borough was obtained both for the current situation, and historically back to 1926. Socioeconomic characteristics of the boroughs were extracted from 1971 census data. Differential mortality experiences for each sex were analysed using the standardised mortality ratio for ages 25 to 74. Most of the causes of death examined were associated with one or more of the socioeconomic characteristics of the boroughs. These socioeconomic characteristics accounted for the statistical associations between water reuse and mortality for each cause studied, except male stomach cancer, where a weak residual association remained. This association disappeared when variation in the size of boroughs was taken into account.

Health related studies of organic compounds in relation to re-use in the United Kingdom

Approximately one third of the water supplies in the United Kingdom are derived from lowland rivers receiving industrial and domestic effluent and in some cases the level of indirect re-use may be high. Research, funded by the Department of the Environment, is being undertaken to identify any potentially hazardous organic compounds that may be present in such supplies and to determine whether there is evidence of any effects on the health of the relevant populations. Analysis of drinking water from various types of source has shown that a wide variety of organic compounds is present in drinking water derived from groundwater and polluted lowland rivers but with few exceptions concentrations are much higher in the latter case. The mutagenicity screening of water samples as a means of directing analytical effort at the substances of greatest potential health significance is being investigated. In a study of cancer mortality in 29 London boroughs an association between high levels of re-use and cancers of the gastrointestinal and urinary tracts disappeared when socioeconomic characteristics and borough size were taken into account. A national study is now being undertaken.

The mode of inheritance of blood pressure levels

In a sample of 465 families living in a suburb of north-west London the systolic and diastolic blood pressure consistently showed a greater correlation for sib/sib (0.16 to 0.28) than for parent/offspring (0.07 to 0.18); this pattern is consistent with the hypothesis of a dominance component in the inheritance of blood pressure assuming there is no difference in the interaction between environment and genes in people of different ages. This assumption was examined by studying the sib/sib correlation according to the age gap between sibs; for diastolic blood pressure this remained almost the same but for systolic blood pressure the correlation tended to diminish as the age gap increased. A dominance component in the inheritance of blood pressure levels could explain the sort of results we have found in this study. However, we cannot ignore the fact that similar results could be obtained if the contribution of the environment within the same generation of relatives differs from that of the environment shared by all relatives.

Varicose veins: A comparison of surgery and infection/compression sclerotherapy. Five-year follow-up

A randomised controlled trial was carried out to compare the clinical outcome 5 years after inpatient surgery and outpatient injection/compression sclerotherapy. 91.3% of those originally treated by injection/compression sclerotherapy and 93.9% of those originally treated surgically were seen at follow-up. 40% of patients treated initially by injection/compression sclerotherapy and 24.2% of those treated surgically were given further treatment. The probability of having no further treatment is significantly greater for those treated surgically. The improved outcome after surgery increased with age, being most striking in those aged over 45. The implications of the 5-year follow-up findings for the long-term cost of treatment are discussed.

Concordance of blood pressure in spouses

It has been known for some years that familial aggregation of blood pressure levels occurs in adults. The question of how much of this aggregation can be attributed to genetical inheritance, and how much to a shared environment, is not yet resolved. Evidence of the influence of a common environment on blood pressure levels can be gained from examining spouses who are not genetically related. In a family study of blood pressure levels in children, 452 of the parents had had a single continuous marriage. These spouses had a small but significant association with respect to blood pressure, and this association varied with length of marriage. Different interpretations of this result are discussed in relation to those from longitudinal studies.

Factors influencing demand for primary medical care in women aged 20-44 years: a preliminary report

This paper reports on a study designed to relate certain social and psychological variables to demand for medical care in a random sample of female patients aged between 20 and 44 years, in a National Health Service General Practice in the United Kingdom. Women selected for study completed questionnaires on anxiety and on their social characteristics. They also completed a health diary for four weeks, and over 12 months their demand for general practitioner care was recorded. This paper summarizes some of the literature on the subject of utilization behaviour, describes the objectives and methodology, and gives some preliminary results suggesting associations between anxiety, perception of symptoms and demand for primary care.