The seven countries study: 2,289 deaths in 15 years

Phytoestrogens: Potential Benefits and Implications for Breast Cancer Survivors

Phytoestrogens are a group of plant-derived substances that are structurally or functionally similar to estradiol. There has been much interest in the potential role of phytoestrogens in cancer prevention and treatment of estrogen-deficient states. This review summarizes the evidence for phytoestrogen risks and benefits relevant to the breast cancer survivor, including prevention of a second primary breast cancer or metastatic disease, reduction in menopausal symptoms, and interactions with tamoxifen. Epidemiological data suggest a breast cancer protective role for phytoestrogens, and there is some supporting clinical data, but they are far from conclusive. In addition, there is some evidence that genistein, the most prevalent isoflavone in soy, can stimulate estrogen receptor-positive (ER+) breast cancer growth and interfere with the antitumor activity of tamoxifen at low levels. Given current knowledge, women who have ER+ tumors should not increase their phytoestrogen intake. Several studies suggest an inhibitory effect on ER- breast cancer cell growth, and it may be reasonable for women with ER- tumors to safely consume soy and possibly other phytoestrogens. However, the optimal amount and source are not clear. More research is needed to clarify the role of phytoestrogens in breast cancer prevention and in treating estrogen-deficient diseases in women who have had breast cancer.

Lovastatin and beyond: the history of the HMG-CoA reductase inhibitors

In the 1950s and 1960s, it became apparent that elevated concentrations of plasma cholesterol were a major risk factor for the development of coronary heart disease, which led to the search for drugs that could reduce plasma cholesterol. One possibility was to reduce cholesterol biosynthesis, and the rate-limiting enzyme in the cholesterol biosynthetic pathway, 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase, was a natural target. Here, I describe the discovery and development of lovastatin--the first approved inhibitor of HMG-CoA reductase--and the clinical trials that have provided the evidence for the ability of drugs in this class to reduce the morbidity and mortality associated with cardiovascular disease.

Prediction of coronary heart disease: a comparison between the Copenhagen risk score and the Framingham risk score applied to a Dutch population

OBJECTIVES

To compare the estimation of coronary heart disease (CHD) risk by the Framingham risk score (FRS) and the Copenhagen risk score (CRS) using Dutch population data.

DESIGN

Comparison of CHD risk estimates from FRS and CRS. CHD risk-estimations for each separate risk factor.

SETTING

Urk, the Netherlands.

SUBJECTS

A total of 408 fishermen from Urk, aged 30-65 years, without pre-existing cardiovascular disease.

MAIN OUTCOME MEASURES

Absolute CHD risk estimates.

RESULTS

The average 10-year risk for CHD was significantly different between the FRS (4.6%, SD 5.0) and the CRS (3.2%, SD 4.1). The correlation between the two estimates was 0.94 (P < 0.001). The Bland-Altman figure shows a large proportion of agreement, but with an increasing difference with increasing average risk. When examining the separate risk factors age, total cholesterol, HDL cholesterol and systolic blood pressure and smoking, there appear differences between the two risk functions.

CONCLUSION

Using Dutch population data, differences were found for the calculation of CHD risk with the FRS and the CRS. Further research must be carried out to examine the validity of these risk functions in the Dutch population.

Dietary supplementation with fermented soybeans suppresses intimal thickening

Although soy foods have been consumed for more than 1000 y, it is only in the past 20 y that they have made inroads into Western diets. We investigated the effect of dietary supplementation with natto extracts produced from fermented soybeans on intimal thickening of arteries after vessel endothelial denudation. Natto extracts include nattokinase, a potent fibrinolytic enzyme having four times greater fibrinolytic activity than plasmin. Intimal thickening was induced in the femoral arteries by intravenous infusion of rose bengal followed by focal irradiation with a transluminal green light. Dietary natto extract supplementation was started 3 wk before endothelial injury and continued for another 3 wk after. In ex vivo studies, euglobulin clot lysis times were measured 3 wk after the initial supplementation. Neointima formation and thickening were also initiated successfully. The intima media ratio 3 wk after endothelial injury was 0.15 +/- 0.03 in the control group. Dietary natto extract supplementation suppressed intimal thickening (0.06 +/- 0.01; P < 0.05) compared with the control group. Natto extracts shortened euglobulin clot lysis time, suggesting that their thrombolytic activities were enhanced. These findings suggest that natto extracts, because of their thrombolytic activity, suppress intimal thickening after vascular injury as a result of the inhibition of mural thrombi formation.

A simple estimate of mortality attributable to excess weight in the European Union

OBJECTIVE

To estimate the current burden of mortality attributable to excess weight in the European Union (EU).

METHODS

Prevalence of overweight (body mass index, BMI 25-29.9 kg/m(2)) and obesity (BMI >or=30 kg/m(2)) were based on self-reported data from a survey with samples representative of the 15 EU Member States in 1997. Primary source of relative risk (RR) of death by BMI was the first American Cancer Prevention Study (CPS I). Additional calculations were performed to account for effect of smoking (using CPS I data for non- or never-smokers), for pre-existing illness (using the second CPS, CPS II, data for healthy never-smokers) and using RRs derived from European rather than US data (using data from a meta-analysis of prospective studies). Mortality attributable to excess weight was calculated by combining the prevalences of overweight and obesity, the RRs, and the number of deaths in the EU countries.

RESULTS

Annual deaths attributable to overweight and obesity totalled approximately 279 000 when RRs for all subjects were used. When RRs for nonsmokers only were applied to the entire population, about 304 000 deaths were attributable to excess weight. In analyses using RRs which controlled for both smoking and history of disease, the number of deaths attributable to excess weight was estimated at about 337 000 based on European data and at about 401 000 based on US data. In the EU, therefore, a minimum of 279 000 deaths were attributable to excess weight (7.7% of all deaths, varying from 5.8% for France through 8.7% for the UK). More attributable deaths occurred among the obese (175 000) than among the overweight (104 000). Around 70% were cardiovascular disease deaths (195 000) and 20% cancer deaths (53 000).

CONCLUSION

Mortality attributable to excess weight is a major public health problem in the EU. At least one in 13 annual deaths in the EU are likely to be related to excess weight.

Endothelial dysfunction and the metabolic syndrome

The metabolic syndrome is a highly prevalent multifaceted clinical entity produced through the interaction of genetic, hormonal, and lifestyle factors. A distinctive constellation of abnormalities precedes and predicts the accelerated development of inflammation and coagulation represent emerging risk contributors associated with obesity and insulin resistance, central components of the metabolic syndrome, which act in concert with traditional abnormalities to increase cardiovascular risk. The initiation and progression of atherosclerosis may have its origins in impaired endothelial function that can be detected at the earliest stages of development of the syndrome. The basic elements of the metabolic syndrome and accelerated phase of atherogenesis are often silent partners that present many years before the onset of type 2 diabetes mellitus. The ability to detect and monitor subclinical vascular disease, as a reflection of the multiple factors that contribute to impair arterial wall integrity, holds potential to further refine cardiovascular risk stratification. Noninvasive assessment of vascular health may also aid the clinical decision-making process by guiding therapeutic interventions to optimize vascular protection in the metabolic syndrome.

Event rates of acute myocardial infarction and coronary deaths in Niigata and Nagaoka cities in Japan

Mortality from coronary heart disease in Japan is the among lowest recorded in the industrialized nations; however, little is known about the rate of events including nonfatal cases. A survey of event registration and a review of death certificates was carried out to estimate event rates of acute myocardial infarction (AMI) and coronary deaths in the largest 2 cities of the Niigata prefecture where there are 480,720 residents aged between 15 and 65 years. The definitions for these cardiac events used for the WHO-MONICA project were: (1)'definite AMI', (2) 'possible AMI or coronary death' (not including unclassifiable fatal events), and (3) 'unclassifiable fatal events'. Age-adjusted rates for AMI and coronary deaths (per 100,000/year) according to the registration survey were 54.6 for men and 7.2 for women according to definition 1 and 41.9 for men, and 5.3 for women according to definition 2. When data from the death certificate review were taken into account for the estimation, these rates increased to 80.6 for men and 14.2 for women according to definition 1, and 50.0 for men and 9.0 for women according to definition 2. These estimated rates are considerably lower than those in other industrialized nations surveyed in the WHO-MONICA project, and these findings are consistent with those from other studies conducted in Japan.

Diet composition and the metabolic syndrome: what is the optimal fat intake?

Two cholesterol-raising fatty acids in the diet, saturated fatty acids and trans fatty acids, increase the serum low-density lipoprotein cholesterol concentration. This fact justifies the recommendation of a reduced intake of cholesterol-raising fatty acids. Emerging data suggest that diets higher in unsaturated fatty acids, particularly monounsaturated fatty acids, have several advantages over high-carbohydrate intakes. This advantage appears to hold, particularly for populations having a high prevalence of insulin resistance, such as the US population. If the US public were to modify its eating habits in the direction of better weight control and more exercise, higher intakes of carbohydrate might be better tolerated. At the same time, the experience with the Mediterranean population reveals that in healthier populations, diets relatively high in unsaturated fatty acids are well tolerated and are associated with a low prevalence of both coronary heart disease and type 2 diabetes.

Significance of small dense low-density lipoproteins and other risk factors in patients with various types of coronary heart disease

BACKGROUND

It remains unclear how closely the small dense low-density lipoprotein (LDL) (diameter < or =25.5 nm) is associated with various types of coronary heart disease (CHD) in Japanese patients, an ethnic group with lower serum cholesterol levels and less massive obesity compared with Western populations.

METHODS AND RESULTS

We measured mean LDL particle diameter by gradient gel electrophoresis in 571 patients with CHD and in 263 healthy subjects who served as control patients. Patients with CHD were classified into acute coronary syndrome (ACS), stable CHD and vasospastic angina. High-density lipoprotein cholesterol and apolipoprotein-A1 and -B were significantly different between patients with CHD and controls. LDL size in patients with CHD was markedly smaller than that in controls in both men and women (25.5 +/- 0.7 vs 25.9 +/- 0.4 and 25.7 +/- 0.7 vs 26.0 +/- 0.5 nm, respectively). LDL cholesterol was significantly higher in patients with ACS than in other groups. Plasma levels of high-density lipoprotein cholesterol decreased as the number of diseased vessels or angiographic coronary severity evaluated by Gensini score increased, but the LDL size was comparable irrespective of the type of CHD and the extent and severity of the lesions. Multiple logistic regression analysis revealed that small dense LDL was independently associated with the incidence of CHD in both sexes (odds ratio [OR] 3.5, 95% CI 2.1-5.7, and OR 2.9, 95% CI 1.5-5.6, P <.005).

CONCLUSION

Our study suggests that the small dense LDL is strongly associated with various types of CHD, independent of traditional and nontraditional coronary risk factors, but is not related to the severity and extent of the coronary lesions.

A spread enriched with plant sterol-esters lowers blood cholesterol and lipoproteins without affecting vitamins A and E in normal and hypercholesterolemic Japanese men and women

The objective of the study was to investigate whether different initial baseline cholesterol levels modulate the efficacy of a spread enriched with plant sterol-esters (PS) in lowering blood cholesterol in a Japanese population consuming their usual diet. Healthy adults with a mean age of 45 y and mean plasma total cholesterol (TC) level of 6.5 mmol/L were recruited to participate in a double-blind trial comprised of a run-in period of 1 wk, followed by two intervention periods of 3 wks in a 2 x 2 crossover design and a post-trial follow-up of 3 wk. Volunteers consumed two spreads, one enriched with PS (12 g/100 g plant sterols) and a control spread not fortified with PS. Recommended spread intake was 15 g/d. Effects on plasma lipids, lipoproteins, beta-carotene and vitamins A and E were assessed. Plasma TC and LDL cholesterol (LDL-C) concentrations were 5.8 and 9.1% lower, respectively, when subjects consumed the PS spread than when they consumed the control spread (P < 0.001). Subjects were divided into two groups [normal and mildly cholesterolemic (TC <5.7 mmol/L) and hypercholesterolemic (TC >/= 5.7 mmol/L)]. Reductions (P < 0.001) in TC and LDL-C due to treatment in the former group were 4.9 and 7.9%, respectively. In the hypercholesterolemic group, the reductions (P < 0.001) were 7.1 and 10.6%, respectively. The decreases did not differ between normal/mildly cholesterolemic and hypercholesterolemic subjects. Plasma apolipoprotein B (apoB) and remnant-like particle (RLP) cholesterol (RLP-C) concentrations were lower when subjects consumed the PS spread (44.3 g/L) than the control spread (49.7 g/L). Plasma beta-carotene concentration was lower (P < 0.001) in subjects consuming the PS spread than in the control. Changes in plasma vitamins A and E levels did not differ after intake of the PS and control spreads. In conclusion, consumption of a PS-enriched spread effectively lowered plasma TC, LDL-C, apoB and RLP-C regardless of baseline plasma TC at an intake of 1.8 g/d of plant sterols.

Large scale cohort study of the relationship between serum cholesterol concentration and coronary events with low-dose simvastatin therapy in Japanese patients with hypercholesterolemia

Hyperlipidemia is a well-established risk factor for primary coronary heart disease (CHD). Although simvastatin is known to lower serum lipid concentrations, the protective effect of such lipid-lowering therapy against primary CHD has not been established in Japanese patients with hypercholesterolemia. The Japan Lipid Intervention Trial was a 6-year, nationwide cohort study of 47,294 patients treated with open-labeled simvastatin (5-10 mg/day) and monitored by physicians under standard clinical conditions. The aim of the study was to determine the relationship between the occurrence of CHD and the serum lipid concentrations during low-dose simvastatin treatment. Simvastatin reduced serum concentrations of total cholesterol (TC), low-density lipoprotein- cholesterol (LDL-C) and triglyceride (TG), by 18.4%, 26.8% and 16.1% on average, respectively, during the treatment period. The risk of coronary events was higher when the average TC concentration was > or =240 mg/dl and the average LDL-C concentration was > or =160 mg/dl. The incidence of coronary events increased in the patients with TG concentration > or =300 mg/dl compared with patients with TG concentration <150 mg/dl. The high-density lipoprotein cholesterol (HDL-C) inversely correlated with the risk of coronary events. The J-curve association was observed between average TC or LDL-C concentrations and total mortality. Malignancy was the most prevalent cause of death. The health of patients should be monitored closely when there is a remarkable decrease in TC and LDL-C concentrations with low-dose statin. A reasonable strategy to prevent coronary events in Japanese hypercholesterolemic patients without prior CHD under low-dose statin treatment might be regulating the serum lipid concentrations to at least <240 mg/dl for TC, <160 mg/dl for LDL-C, <300 mg/dl for TG, and >40 mg/dl for HDL-C.

Risk stratification of obesity as a coronary risk factor

We examined the extent of coronary heart disease (CHD) risk factor clustering in overweight persons with a body mass index (BMI) of 25 to 29 and an obesity BMI of >/=30 and the influence of this on the hazard of myocardial infarction and coronary mortality. A total of 1,309 men and 739 women aged 30 to 74 years, initially free of cardiovascular disease, comprised the overweight subject group, and 375 men and 356 women comprised the obese subject group at risk. The sample was derived from the original Framingham Study cohort at the 11th biennial examination, and their offspring at initial examination. During 16 years of follow-up of overweight subjects, 188 men and 44 women had CHD events, indicating an age-adjusted rate that was not much different from the slim subjects. In the obese subject group, 72 men and 37 women developed CHD, corresponding to age-adjusted risk ratios 1.48 times that of lean men, and 2.09 times that of lean women. Risk factors were categorized as systolic blood pressure >/=140 mm Hg, total cholesterol >/=240 mg/dl, high-density lipoprotein (HDL) cholesterol <35 mg/dl for men and <40 mg/dl for women, heart rate >80 beats/min, history of smoking, history of type 2 diabetes, and electrocardiographic left ventricular hypertrophy. Being overweight occurred in isolation of CHD risk factors in 22% of men and in 16.4% of women. Being obese occurred in isolation in only 12.8% of men and 9% of women. Clusters of >/=2 risk factors occurred in 56% of obese men and in 62.4% of obese women, a frequency substantially exceeding that in slim subjects. Compared with obese men without risk factors, those with >/=3 factors had a 2.07 age-adjusted relative risk of developing CHD, and obese women had a 10.9 relative risk (p <0.05). Being overweight and obese promotes clusters of CHD risk factors that greatly influence their impact. Global risk assessment can identify high-risk overweight candidates for CHD who most urgently need correction of associated risk factors, as well as sustained weight reduction.

An increased number of very-low-density lipoprotein particles is strongly associated with coronary heart disease in Japanese men, independently of intermediate-density lipoprotein or low-density lipoprotein

BACKGROUND

Japanese patients with coronary heart disease (CHD) usually have slightly elevated triglyceride levels but virtually normal low-density lipoprotein (LDL)-cholesterol levels.

DESIGN

Case-control study.

METHODS

To explore the atherogenecity of mild hypertriglyceridemia, we measured very-low-density lipoprotein (VLDL) composition and apolipoprotein (apo) B in VLDL, intermediate-density lipoprotein (IDL), light LDL and dense LDL fractions separated by ultracentrifugation in 61 men with angiographically proven CHD and in 69 men without CHD. Apo B, E, C1 and C3 in VLDL were measured by enzyme-linked immunosorbent assay.

RESULTS

Although total- and LDL-cholesterol levels were similar in CHD and control participants, triglyceride levels were significantly higher and high-density lipoprotein (HDL)-cholesterol levels were lower in CHD patients. Triglyceride, cholesterol and apo C1 and E levels in VLDL were two-fold higher and VLDL-apo B level was three-fold higher in CHD than control patients. IDL-triglyceride levels were significantly elevated in CHD, but IDL-cholesterol level was not. Apo B levels of the dense LDL fraction were significantly elevated in CHD groups, but those of the light LDL fraction were not. These differences were constant when triglyceride levels matched between both groups. Multiple logistic regression analysis revealed that the VLDL-apo B and VLDL-apo C1 levels were significantly associated with the incidence of CHD independent of the plasma triglyceride, HDL-cholesterol or apo B levels in dense LDL.

CONCLUSION

These results suggest that an increased number of VLDL particles is strongly associated with CHD, independently of traditional risk factors or newly recognized atherogenic lipoproteins, such as IDL or small, dense LDL, in Japanese men.

A comparison of the Framingham and European Society of Cardiology coronary heart disease risk prediction models in the normative aging study

BACKGROUND

A number of prediction models have been developed in an attempt to accurately identify patients at increased risk of a first coronary heart disease event. We sought to determine the ten-year incidence of coronary heart disease events in a healthy cohort with measurable risk factors, and to compare these results with the predicted number of events by use of both the Framingham and European Society of Cardiology risk prediction models.

METHODS

We compared the predicted and observed number of events in 5 risk categories in 1393 subjects aged 30 to 74 years who were enrolled in the Normative Aging Study.

RESULTS

The risk prediction models reliably stratify populations with regards to relative risk of coronary heart disease events and there is reasonable agreement between the 2 models (weighted kappa = 0.46, P <.01). The Framingham model underestimated the absolute risk of coronary heart disease events in the low-risk group, and both risk prediction models overestimated the absolute risk of events in the high- or very-high-risk groups (Framingham c-statistic = 0.60, European Society of Cardiology c-statistic = 0.58).

CONCLUSIONS

Despite simplification, the accuracy of the European model was not significantly different from the Framingham model. But the accuracy of absolute risk prediction, particularly at the extremes of risk, is imperfect. Refinement and validation of these risk prediction models is important because they affect the management of individual patients and the allocation of community resources.

Effects of sirolimus on lipids in renal allograft recipients: an analysis using the Framingham risk model

This report describes the effects of sirolimus on plasma lipids, and uses the Framingham risk model to assess the clinical importance of these effects. Lipid data from two large controlled studies of 1295 renal transplant patients were analyzed retrospectively. Sirolimus 2 mg/day and 5 mg/day were compared with placebo or azathioprine, and administered concomitantly with steroids and cyclosporine over 12 months. Hypercholesterolemia and hypertriglyceridemia occurred in all treatment groups and were maximal at 2-3 months. The sirolimus groups evidenced higher lipid levels than the controls, but the elevations diminished over time. At 1 year, the patients given sirolimus 2 mg/day had a mean cholesterol level 17 mg/dL greater and a mean triglyceride level 59 mg/dL greater than the controls. Among the patients given sirolimus 5 mg/day, mean cholesterol was 30 mg/dL greater and mean triglycerides were 103 mg/dL greater than the controls. Treatment with statins and fibrates was effective in reducing cholesterol and triglyceride levels, respectively, in the sirolimus-treated patients. The Framingham risk model predicted that the 17 mg/dL elevation in cholesterol would increase the incidence of coronary heart disease (CHD) by 1.5 new cases per 1000 persons per year and CHD death by 0.7 events per 1000 persons per year. Lipid elevations observed in the sirolimus-treated patients were manageable, improved over time, and responded to lipid-lowering therapy. Based on the Framingham risk model, the CHD risks associated with these cholesterol elevations are small compared with the baseline risks of the transplant population.

Use of alternative therapies in menopause

Hormone replacement therapy has traditionally been used to treat the accompanying symptoms of oestrogen deficiency in menopause. However, not all women can, or prefer to, receive this treatment and alternatives should be considered to reduce the increased risk of osteoporosis and heart disease in menopausal women. This chapter reviews the current literature on the efficacy of phyto-oestrogens in preventing cardiovascular disease, various cancers and osteoporosis, as well as treating the vasomotor and other menopause-related symptoms. Select herbal therapies, as well as selective oestrogen receptor modulators, are also considered.

Maintaining the endothelium: preventive strategies for vessel integrity

The endothelium is a diaphanous membrane, only one cell layer thick, that lines all of our blood vessels. Despite its apparent fragility, it exerts profound control over vascular tone, structure, and intersection with circulating blood elements. One of the factors that the endothelium synthesizes is nitric oxide, which is the most potent endogenous vasodilator known. In addition to its blood flow regulating effects, nitric oxide also inhibits key processes in atherosclerosis, including monocyte adherence, platelet aggregation, and proliferation of vascular smooth muscle cells. Nitric oxide synthesis is impaired, and its degradation is accelerated, in many of the conditions associated with atherosclerosis, including hypercholesterolemia. Restoration of nitric oxide synthesis and activity in these disorders can improve blood flow, relieve symptoms, and perhaps reduce the progression of atherosclerosis.(c) 2001 by CHF, Inc.

Trends in lifestyle cardiovascular risk factors in women: analysis from the Canadian National Population Health Survey

Cardiovascular disease (CVD) is the leading cause of death and disability among women. The present investigation analyzed data from the National Population Health Survey to examine the prevalence trends of self-reported lifestyle CVD risk factors in adult women. Results indicated an upward prevalence trend in physical activity and high blood pressure, and significant increased prevalence rates in obesity in the lower middle and middle income groups. Logistic regression analysis showed that increased physical activity and advancing age were significant predictors of CVD; age confers more than a one-fold risk for developing heart disease and hypertension. Implications of the study results for nursing practice are discussed.

Secular growth and its harmful ramifications

Secular growth has been occurring in Europe for about 150 years. In the USA, since 1900, each new generation has increased by an average of 1in (2.54cm) in height and about 10lb (4.54kg) in weight. This trend has generally been viewed as favorable and tallness is admired, with the current ideal height for a man in the Western world being 6ft 2in (188cm). The Japanese have increased in height since the end of the Second World War by about 5in (12.7cm) in height and the Chinese have been growing at the rate of 2.54cm/decade since the 1950s. In spite of admiring greater height, a world population of increasing height and body-weight is a major threat to our environment, health and survival. Based on more than two decades of research, quantitative data are given for increased use of resources, and increased pollution, energy and fiscal costs resulting from a population of larger people. The laws of scaling are described to show why the impact of increasing stature has a non-linear impact on consumption, body-weight, strength, pollution and economic costs. Paleontological findings indicating that larger body size increases the risk of extinction are also discussed. Various studies indicate a loss of 0.47 year of longevity for each cm increment of height. Caloric restricted diets are also reviewed for their applicability to humans. Recommendations are made for dietary practices to moderate growth in our youth and to postpone development of chronic or degenerative diseases.

Remarkably high prevalence of small dense low-density lipoprotein in Japanese men with coronary artery disease, irrespective of the presence of diabetes

To examine how prevalence of the small dense LDL phenotype (LDL particle diameter < or =25.5 nm) is associated with coronary artery disease (CAD) in type 2 diabetic and non-diabetic Japanese men, an ethnic group with a low incidence of CAD, 85 non-diabetic men and 45 type 2 diabetic men with angiographically documented CAD, and 142 control men and 76 type 2 diabetic men without CAD were studied. Mean LDL particle diameter was determined using 2-16% polyacrylamide gel electrophoresis. LDL particle diameters in CAD patients were much smaller than those in controls (25.2+/-0.7 vs. 26.0+/-0.4 nm, mean+/-S.D., P<0.0001). LDL size was smaller in diabetic subjects (25.6+/-0.6 nm) and became even smaller in diabetics with CAD (25.0+/-1.0 nm). Prevalence of small dense LDL was markedly higher in both non-diabetic and diabetic CAD patients than that in non-diabetic and diabetic patients without CAD (71, 76, 23 and 42%, respectively). CAD patients had lower HDL-cholesterol and apo A1 levels, and higher triglyceride levels than those in diabetic and non-diabetic CAD-free patients, while total- and LDL-cholesterol levels were even lower in CAD group, and remnant-like particle-cholesterol, lipoprotein (a) and insulin levels were comparable among four groups. LDL size was significantly associated with triglyceride, HDL-cholesterol and glycemic control. Logistic regression analysis revealed that the small dense LDL phenotype was significantly associated with the incidence of CAD independent of low levels of HDL-cholesterol or high levels of triglyceride in both non-diabetic and diabetic cases. These results suggest that high prevalence of small dense LDL is a leading cause of CAD in both diabetic and non-diabetic Japanese men. Type 2 diabetes shows a greater capacity to reduce LDL size, which may contribute to the high incidence of CAD in the diabetic population.

Application of the updated Framingham risk score to Japanese men

Few tools for risk assessment of coronary heart disease (CHD) have yet been made available in Japan. This study aims to examine the validity of the updated Framingham risk score as applied to a Japanese male population. Using the annual health examination database of a Japanese company, we followed-up 5,611 male subjects, aged 30 to 59 years, who had initially recorded neither history of cardiovascular disease nor electrocardiographical ischemic changes, in order to observe the occurrence of CHD over a period of 5 to 7 years. The total score calculated by the Framingham risk score sheet (the Framingham point score) was used as an indicator of CHD risk for the subject individually. The mean of the Framingham point score for 80 CHD cases was significantly higher than that for 5,531 non-CHD cases. The incidence of CHD gradually increased with the Framingham point score. In the receiver operating characteristic analysis, the area under the curve reached 0.71. At 6 points, the curve came closest to the upper left-hand corner, with a specificity of 0.74 and sensitivity of 0.59. On the other hand, multivariable-adjusted relative risks associated with old age, high blood pressure, low HDL cholesterol and smoking in the Japanese male population were different from those in the Framingham population. Despite the low incidence of CHD, the updated Framingham risk score could provide a reasonable rank ordering of CHD risk and could identify Japanese men (and possible other individuals) at high risk for CHD with considerable accuracy. However, further study of Japanese populations may be required to reappraise several coefficients of risk factor in the risk scoring model.

Economic impact of community pharmacist intervention in cholesterol risk management: an evaluation of the study of cardiovascular risk intervention by pharmacists

The Study of Cardiovascular Risk Intervention by Pharmacists, a randomized, controlled trial in over 50 community pharmacies in Alberta and Saskatchewan, Canada, demonstrated that a pharmacist intervention program improved cholesterol risk management in patients at high risk for cardiovascular disease. In a substudy, costs and consequences were analyzed to describe the economic impact of the program. Two perspectives were taken: a government-funded health care system and a pharmacy manager. Costs were reported in 1999 Canadian dollars. Incremental costs to a government payor and community pharmacy manager were $6.40/patient and $21.76/patient, respectively, during the 4-month follow-up period. The community pharmacy manager had an initial investment of $683.50. The change in Framingham risk function for the intervention group from baseline also was reported. The 10-year risk of cardiovascular disease decreased from 17.3% to 16.4% (p<0.0001) during the 4 months. The intervention program in this study led to a significant reduction in cardiovascular risk in the intervention group during the 4-month follow-up period. The incremental cost to provide the program appeared minimal from both government and pharmacy manager perspectives. It is hoped that these results could support negotiations for reimbursement of clinical pharmacy services with payors.

[Risk factors and coronary morbimortality in a Mediterranean industrial cohort over 28 years of follow-up. The Manresa Study]

OBJECTIVE

To study the incidence and mortality of coronary heart disease (CHD) and all-cause mortality in a cohort of men followed during 28 years, and their association with serum cholesterol, systolic blood pressure, glycemia, cigarette smoking and body mass index measured at baseline.

RESEARCH DESIGN AND METHODS

A cohort of 1,059 men aged 30 to 59 years and free of cardiovascular diseases at baseline in 1968, was examined every five years until 1988. The last examination was performed in 1996. Information was collected in 96.4% of the participants.

RESULTS

Incidence and mortality rates from CHD and from all-causes of death per 105 person-years of observation were 499.80, 235.80 and 925.33, respectively. At the end of follow-up, high levels of serum cholesterol and smoking were independently associated with the incidence and mortality from CHD adjusted for age, blood pressure, glycemia and BMI. Serum cholesterol, hyperglycemia and smoking were independently associated with all-cause mortality.

CONCLUSIONS

In this industrial cohort of men, with a relatively low incidence of CHD, smoking and serum cholesterol at baseline were independently associated with the incidence of CHD over 28 years of observation.

The role of risk factors in the development of atherosclerosis

Our understanding of risk factors for atherogenesis has changed significantly over the last decade. In addition to better grasp of the mechanism of action of the "classic" (causal) risk factors, a number of potentially important new factors has emerged. In this review we briefly summarize the evidence of the relation between atherosclerosis and the currently recognized causal risk factors, namely, age, smoking, LDL cholesterol, HDL cholesterol, hypertension, and diabetes. More emphasis has been put on description of the emerging entities such as atherogenic profile of plasma lipoproteins with discussion of LDL and HDL subclasses, Lp(a), homocysteine, and, last but not least, on the role of infection and inflammation in atherogenesis. Whenever possible, we tried to summarize the relevant lines of evidence such as epidemiological, pathological, genetic, and clinical trial data linking the specific factor with atherosclerosis.

Blood pressure and cardiovascular morbidity and mortality in a Dutch population: the Nijmegen cohort study

BACKGROUND

The objective was to determine the influence of systolic blood pressure and diastolic blood pressure on the development of coronary heart disease over an 18-year period in a Dutch general practice population.

METHODS

The Nijmegen Cohort Study is a prospective cohort study with an 18-year follow-up. In 1977 systolic blood pressure, diastolic blood pressure, and other cardiovascular risk factors were measured in 7,092 Caucasians, men and women. The screening took place in six general practices, participating in a university registration network. Cardiovascular disease and all mortality was registrated during the 1977-1995 period. A Cox proportional hazard model was performed separately for men and women with the first onset of a coronary heart disease as the outcome variable. Age, smoking, serum cholesterol, blood pressure, and socioeconomic class were included as independent variables.

RESULTS

During the 18-year follow-up period, 205 men and 63 women suffered a nonfatal myocardial infarction. During this time, 205 deaths were identified, of which 54 were cardiovascular. Of all deaths, 139 were noncardiovascular, of which 10% were due to accident or suicide, while in 12 participants the cause of death was uncertain. The analysis indicated that both the systolic and the diastolic blood pressure were independently associated with the likelihood for developing coronary heart disease, as were the other risk factors. For coronary heart disease, the significant risk ratios for the systolic blood pressure were 1.6 for men and 2.1 for women. For the diastolic blood pressure a risk ratio was found of 1.4 for men and 2.0 for women.

CONCLUSION

A significant relation between blood pressure and coronary heart disease was demonstrated. As mean blood pressures, cholesterol levels, smoking habits, and socioeconomic class in this cohort did not differ from other figures in The Netherlands, extrapolation of the results to the Dutch population is possible.

Obesity, body fat distribution and coronary atherosclerosis among Japanese men and women

OBJECTIVE

To investigate the relation of the obesity and body-fat distribution with angiographically defined coronary atherosclerosis.

DESIGN

Cross-sectional study in a clinical setting.

SUBJECTS

Three hundred and twenty men (median age, 59 y) and 212 women (median age, 67 y) who underwent coronary angiography for suspected or known coronary heart disease at 5 cardiology departments between September 1996 and August 1997. Patients with disease duration >1 y were excluded.

MEASUREMENTS

The body mass index (BMI) and the waist to hip circumference ratio (WHR) were used as main exposure variables, and either the presence of significant coronary stenosis or the Gensini's score (> or =10 vs<10) as an outcome variable, in a sex-specific multiple logistic regression analysis controlling for age, hospital, and other coronary risk factors.

RESULTS

Among male patients, BMI was progressively higher with an increasing number of vessels involved (P trend=0.05); the adjusted odds ratios for the presence of significant stenosis across quartiles of BMI were 1.0 (reference), 1.1, 1.9 and 2.5 (P trend=0.02), and the positive association was more pronounced for younger patients. Among females, however, such associations were not evident. Employing the Gensini's score as an outcome gave similar results. WHR was not significantly associated with either outcome regardless of sex.

CONCLUSION

These results suggested that BMI was predictive of coronary stenosis among male patients, but not among female patients. Unlike most previous studies, this study failed to detect a positive association with WHR.

Magnitude of sustained multiple risk factors for ischemic heart disease in Japanese employees: a case-control study

A case-control study was performed to clarify the cause of ischemic heart disease (IHD), such as acute myocardial infarction and angina pectoris, in Japanese employees. Among 122,051 workers from 31 industries, 94 cases of IHD were the subjects of the study, and a total of 191 age-matched subjects from the same department, but who did not develop IHD, served as the controls. Compared with the control group, body mass index, blood pressure, fasting plasma glucose, serum total cholesterol and serum triglyceride were significantly higher, and cigarette consumption and serum uric acid also tended to be higher, in the patient group from at least 10 years prior to onset. The frequency of moderate-drinkers tended to be lower in the case group. Electrocardiograms showed that, compared with the control group, the frequency of myocardial ischemia was higher in the case group from 9 years prior to onset and further rapidly increased from 3 years prior. The frequency of subjects with arrhythmia was the same as the control group until 3 years before onset and increased rapidly from 2 years prior. The frequency of subjects with multiple risk factors, particularly obesity, hypertension, hyperlipidemia and hyperglycemia, was consistently higher in the case group compared with the control group from 10 years prior to onset. Conditional logistic regression analysis demonstrated that having more than one risk factor greatly increased the risk; in particular, the combination of 3 or more factors increased the relative risk to 10.56 (95% confidence interval: 3.30-33.78). These findings suggest that a long duration of multiple risks is involved in the onset of IHD in Japanese employees, and that annual ECG monitoring as part of the medical examination was important in the prognosis.

Metabolic complications of obesity

The rising prevalence of obesity is accompanied by an increasing number of patients with the metabolic complications of obesity. The major complications come under the heading of the metabolic syndrome. This syndrome is characterized by plasma lipid disorders (atherogenic dyslipidemia), raised blood pressure, elevated plasma glucose, and a prothrombotic state. The clinical consequences of the metabolic syndrome are coronary heart disease and stroke, type 2 diabetes and its complications, fatty liver, cholesterol gallstones, and possibly some forms of cancer. At the heart of the metabolic syndrome is insulin resistance, which represents a generalized derangement in metabolic processes. Obesity is the predominant factor leading to insulin resistance, although other factors play a role. The mechanistic link between insulin resistance and the metabolic syndrome is complex. The relationship is modulated by yet other factors, such as physical activity, body fat distribution, hormones, and a person's genetic polymorphic architecture. A better understanding of the molecular basis of this relationship is needed to suggest new targets for prevention and treatment of the complications of obesity. In addition, understanding at the clinical level will lead to improved management of these complications.

Comparison of fatal coronary heart disease occurrence based on population surveys in Japan and the USA

BACKGROUND

Although vital statistics have indicated large Japanese-American differences in mortality rates for coronary heart disease (CHD), the magnitude of difference has not been documented well using comparable validation of cause of death.

METHODS

Population-based fatal CHD data were compared between the Oita Cardiac Death Survey, Japan and the Atherosclerosis Risk in Communities (ARIC) Study, USA. Both studies (population: Oita City 198 093; the ARIC comunities 286 820) identified possible fatal CHD events (International Classification of Diseases, Ninth Revision [ICD-9]: 410-414, 250, 401-402, 427-429, 440, and 798-799) among residents aged 35-74 years during 1992-1993. Comparable criteria for classifying cause of death were applied. Sex-specific, age-adjusted mortality rates of CHD were calculated by place of death.

RESULTS

In all, 330 deaths in Oita and 1398 in the ARIC communities had eligible ICD-9 death certificate codes; CHD codes (ICD-9 410-414) comprised 30.6% of investigated deaths in Oita and 58.6% in ARIC. For men, the non-validated rate ratio for CHD deaths (ARIC:Oita City) was 5.9 (95% CI : 4.2-8.5), which fell to 4.7 (95% CI : 3.5-6.4) with validation and inclusion of sudden deaths within one hour of onset as fatal CHD. For women, the overall non-validated rate ratio was 4.6 (95% CI : 2.8-7.6), which fell to 3.9 (95% CI : 2.4-6.3) with validation and but there was little further change when the sudden deaths were added.

CONCLUSIONS

Our results suggest that differences in fatal CHD rates between Japanese and Americans were not as large as suggested by vital statistics when events were validated and sudden deaths were included.

Distribution and determinants of ischaemic heart disease in an urban population. A study from the myocardial infarction register in Malmö, Sweden

OBJECTIVE

Age adjusted incidence of myocardial infarction has been found to vary substantially between the residential areas of the city of Malmö. The objective of this study was to assess the extent to which major biological risk factors and socio-economic circumstances account for the differences in incidence of and mortality from myocardial infarction.

DESIGN

Ecological study of risk factor prevalence and incidence and mortality from myocardial infarction.

SETTING

Seventeen administrative areas in Malmö, Sweden.

SUBJECTS

Assessment of risk factor prevalence was based on 28 466 men and women, ranging from 45 to 73 years old, who were recruited as participants in the Malmö Diet and Cancer study. Information on serum lipids was available in a random subsample of 5362 subjects. Information about socio-economic level of the residential area was based on statistics from the Malmö City Council and Statistics Sweden.

MAIN OUTCOME MEASURES

Weighted least square regressions between prevalence of risk factors (i.e. smoking, hypertension, obesity, diabetes, hypercholesterolemia and hypertriglyceridemia), a myocardial infarction risk score, a socio-economic score and incidence and mortality from myocardial infarction.

RESULTS

The risk factor prevalence and myocardial infarction incidence was highest in areas with low socio-economic level. Prevalence of smoking, obesity and hypertension was significantly associated with myocardial infarction incidence and mortality rates amongst men (all r > 0.60). Prevalence of smoking was significantly associated with incidence and mortality from myocardial infarction amongst women (r = 0.66 and r = 0.61, respectively). A myocardial infarction risk score based on four biological risk factors explained 40-60% of the intra-urban geographical variation in myocardial infarction incidence and mortality. The socio-economic score added a further 2-16% to the explained variance.

CONCLUSION

In an urban population with similar access to medical care, well-known biological cardiovascular risk factors account for a substantial proportion of the intra-urban geographical variation of incidence of and mortality from myocardial infarction. The socio-economic circumstances further contribute to the intra-urban variation in disease.

Albumin synthesis is diminished in men consuming a predominantly vegetarian diet

Albumin synthesis was calculated in healthy male volunteers consuming diets differing in the relative contribution of protein from animal or vegetable sources. In one study (Study 1, n = 4) two isoenergetic and isonitrogenous diets were consumed for a period of 10 d each. One diet (diet A) was animal protein rich (74%), the other one (diet V) contained 67% of vegetable protein. Albumin synthesis rate was measured from L-[(2)H(5)]phenylalanine incorporation (43 mg/kg) at the end of each dietary period. Both albumin fractional synthesis rate (FSR) (5.7 +/- 0.6 vs. 6.7 +/- 0. 8%/d, P = 0.04) and absolute synthesis rate (ASR) (123 +/- 6 vs. 143 +/- 8 mg. kg(-1). d(-1), P = 0.05) were reduced after diet V. In a second study (Study 2, n = 8) a third dietary treatment was added (Diet VS). This was similar to diet V but supplemented with soy protein (18g/d). The results of study 2 confirmed that albumin synthesis was reduced after diet V (FSR: 5.9 +/- 0.3 vs. 6.7 +/- 0. 5%/d, P = 0.015; ASR: 126 +/- 7 vs. 146 +/- 9 mg. kg(-1). d(-1), P = 0.007), but it also showed that the drop could be prevented by adding supplemental protein to the predominantly vegetarian diet (Diet VS) (FSR: 6.4 +/- 0.3%/d, P = 0.08; ASR: 140 +/- 7 mg. kg(-1). d(-1), P = 0.03). Albumin synthesis appears to be modulated by changes in the proportion of animal vs. vegetable protein occurring in the diet. The mechanism might be related to differences in digestibility and consequently in net amino acid availability between diets.

The optimal ratio of fat-to-carbohydrate in the diet

A major issue in human nutrition is the optimal relation of carbohydrate-to-fat in the diet. According to some investigators, a high proportion of fat energy to total energy favors the development of several chronic diseases. Among these are obesity, coronary heart disease, diabetes, and cancer. The theory that a high proportion of fat relative to other nutrients promotes the development of obesity is founded on research with experimental animals and in human population surveys. This theory has been difficult to prove in prospective feeding studies in humans; therefore it remains a contentious issue. Regarding coronary heart disease, little evidence supports a claim that a high proportion of dietary fat predisposes to disease. On the other hand, strong evidence bolsters the claim that certain fatty acids raise the risk for coronary heart disease. These include saturated fatty acids and trans fatty acids, both of which raise serum cholesterol levels. In contrast, neither monounsaturated nor polyunsaturated fatty acids raise serum cholesterol levels and seemingly pose little risk for coronary disease. The relationship between dietary fat and type 2 diabetes is tied largely to the issue of obesity, because obesity is a major cause of diabetes. Although animal studies and epidemiological studies have implicated dietary fat as a factor in cancer, recent prospective epidemiological data in humans have cast doubt on the possibility of a strong relationship. In summary, clear evidence points to the need to reduce intakes of saturated and trans fatty acids in the diet. Beyond this change, a balanced ratio of unsaturated fatty acids to carbohydrate leading to fat intake of approximately 30% of total energy seems appropriate for the American public.

Is the Framingham risk function valid for northern European populations? A comparison of methods for estimating absolute coronary risk in high risk men

OBJECTIVE

To examine the validity of estimates of coronary heart disease (CHD) risk by the Framingham risk function, for European populations.

DESIGN

Comparison of CHD risk estimates for individuals derived from the Framingham, prospective cardiovascular Münster (PROCAM), Dundee, and British regional heart (BRHS) risk functions.

SETTING

Sheffield Hypertension Clinic. Patients-206 consecutive hypertensive men aged 35-75 years without preexisting vascular disease.

RESULTS

There was close agreement among the Framingham, PROCAM, and Dundee risk functions for average CHD risk. For individuals the best correlation was between Framingham and PROCAM, both of which use high density lipoprotein (HDL) cholesterol. When Framingham was used to target a CHD event rate > 3% per year, it identified men with mean CHD risk by PROCAM of 4.6% per year and all had CHD event risks > 1.5% per year. Men at lower risk by Framingham had a mean CHD risk by PROCAM of 1.5% per year, with 16% having a CHD event risk > 3.0% per year. BRHS risk function estimates of CHD risk were fourfold lower than those for the other three risk functions, but with moderate correlations, suggesting an important systematic error.

CONCLUSION

There is close agreement between the Framingham, PROCAM, and Dundee risk functions as regards average CHD risk, and moderate agreement for estimates within individuals. Taking PROCAM as the external standard, the Framingham function separates high and low CHD risk groups and is acceptably accurate for northern European populations, at least in men.

Multivariate risk estimation for coronary heart disease: the Busselton Health Study

Coronary heart disease (CHD) is a multifactorial disease and CHD risk should be estimated by assessing all cardiovascular risk factors simultaneously. Simply adding up the number of factors with 'at risk' values fails to identify high-risk subjects with multiple risk factors at moderately elevated values. A more efficient approach is to use a quantitative multivariate risk score. A number of overseas studies have produced CHD risk scoring systems for men. There are few risk scores developed for women and no CHD risk scores have been developed from Australian data. This study used data on CHD risk factors and morbidity/mortality follow-up for the 1978 Busselton Health Survey participants to provide age-specific estimates of absolute risk of CHD hospitalisation or death, and to develop multivariate CHD risk scoring systems for men and women. The scores are based on age, blood pressure, anti-hypertensive medication, total and HDL cholesterol, smoking, diabetes, left ventricular hypertrophy and previous history of CHD. The generalisability and applicability of these risk estimation systems to Australian populations in the late 1990s is discussed.

Gamma-linolenic acid does not augment long-chain polyunsaturated fatty acid omega-3 status

Augmentation of long chain polyunsaturated omega3 fatty acid (LCPUFA omega3) status can be reached by consumption of fish oil or by improvement of the conversion of alpha-linolenic acid (ALA) to LCPUFA omega3. Since gamma-linolenic acid (GLA) might activate the rate-limiting delta-6 desaturation, we investigated whether GLA augments LCPUFA omega3 status. Eight adults received 1.4 g GLA for 4 weeks and subsequently 2.2 g ALA+1.4 g GLA daily during another 4 weeks. Another seven adults received a daily oral dose of 2.2 g ALA for 4 weeks, and subsequently 2.2 g ALA+1.4 g GLA during another 4 weeks. ALA, or ALA+GLA, did not significantly augment EPA and DHA contents. We conclude that the LCPUFA omega3 status can not be improved by supplementation of low dose GLA, neither by co-supplementation of ALA. Poor conversion of ALA to LCPUFA omega3 may be caused by preferential beta-oxidation of ALA, negative feedback of arachidonic acid from the omnivorous diet, or by the low dietary ALA/LA ratio.

Deceleration in the age pattern of mortality at olderages

The rate of mortality increase with age tends to slow down at very old ages. One explanation proposed for this deceleration is the selective survival of healthier individuals to older ages. Data on mortality in Sweden and Japan are generally compatible with three predictions of this hypothesis: (1) decelerations for most major causes of death; (2) decelerations starting at younger ages for more “selective” causes; and (3) a shift of the deceleration to older ages with declining levels of mortality. A parametric model employed to illustrate the third prediction relies on the distinction between senescent and background mortality. This dichotomy, though simplistic, helps to explain the observed timing of the deceleration.

Comparative total mortality in 25 years in Italian and Greek middle aged rural men

STUDY OBJECTIVE

Mortality over 25 years has been low in the Italian and very low in the Greek cohorts of the Seven Countries Study; factors responsible for this particularity were studied in detail.

PARTICIPANTS AND SETTINGS

1712 Italian and 1215 Greek men, aged 40-59 years, cohorts of the Seven Countries Study, representing over 95% of the populations in designated rural areas.

DESIGN

Entry (1960-61) data included age, systolic blood pressure (SBP), smoking habits, total serum cholesterol, body mass index (BMI), arm circumference, vital capacity (VC), and forced expiratory volume in 3/4 seconds (FEV); the same data were obtained 10 years later. Multivariate Cox analysis was performed with all causes death in 25 years as end point.

MAIN RESULTS

Italian men had higher entry levels of SBP, arm circumference, BMI, and VC; Greek men had higher cholesterol levels, smoking habits, and FEV. Mortality of Italian men was higher throughout; at 25 years cumulative mortality was 48.3% and 35.3% respectively. Coronary heart disease and stroke mortality increased fivefold in Italy and 10-fold in Greece between years 10 and 25. The only risk factor with a significantly higher contribution to mortality in Italian men was cholesterol. However, differences in entry SBP (higher in Italy) and FEV (higher in Greece) accounted for, according to the Lee method, 75% of the differential mortality between the two populations. At 10 years increases in SBP, cholesterol, BMI, and decreases in smoking habits, VC, FEV, and arm circumference had occurred (deltas). SBP increased more and FEV and VC decreased more in Italy than in Greece. Deltas, fed stepwise in the original model for the prediction of 10 to 25 years mortality, were significant for SBP, smoking, arm circumference, and VC in Greece, and for SBP and VC in Italy.

CONCLUSION

Higher mortality in Italian men is related to stronger positive effects of entry SBP and weaker negative (protective) effects of FEV; in addition 10 year increases in SBP are higher and 10 year decreases in FEV are larger in Italy. Unaccounted factors, however, related to, for example, differences in the diet, may also have contributed to the differential mortality of these two Mediterranean populations.

Influences on diet, health behaviours and their outcome in select ethnocultural and religious groups

Diverse cultural components of behavior may have significant impacts on patterns of eating, drinking, and social interaction, irrespective of socioeconomic status. For example, the major world religions prescribe or proscribe specific dietary behaviors; some of these are rooted in historical or geographical origins as well as group folklore; and they have integral roles as expressions of religious piety and group cohesiveness. The literature is replete with ecological observations of between-country differences in disease trends, some of which have been associated with dietary practices. The study of distinct cultural and religious groups (especially migrants acculturating to new environments) and the extent to which they adhere to culturally-based dietary precepts, has advanced our knowledge of psychosocial influences on food habits, nutritional adequacy, and overall health. However, a relatively small proportion of culturally-based research studies conducted to date have explored cross-cultural, ethnic, or religious variables. This paper reviews some population-based differences in dietary habits and other behaviors by ethnocultural group or religious denomination; health consequences and suggestions for future research are discussed.

Healthy traditional Mediterranean diet: an expression of culture, history, and lifestyle

The term Mediterranean diet refers to dietary patterns found in olive-growing areas of the Mediterranean region and described in the 1960s and beyond. There are several variants of the Mediterranean diet, but some common components can be identified: high monounsaturated/saturated fat ratio; ethanol consumption at moderate levels and mainly in the form of wine; high consumption of vegetables, fruits, legumes, and grains; moderate consumption of milk and dairy products, mostly in the form of cheese; and low consumption of meat and meat products. Growing evidence demonstrates that the Mediterranean diet is beneficial to health; the evidence is stronger for coronary heart disease, but it also applies to some forms of cancer. Results from recent investigations provide a strong biomedical foundation for the beneficial effects of the Mediterranean diet.

Prediction of coronary heart disease mortality in Busselton, Western Australia: an evaluation of the Framingham, national health epidemiologic follow up study, and WHO ERICA risk scores

STUDY OBJECTIVES

To evaluate the performance of the Framingham, national health epidemiologic follow up study, and the WHO ERICA risk scores in predicting death from coronary heart disease (CHD) in an Australian population.

DESIGN

Cohort follow up study.

SETTING AND PARTICIPANTS

The cohort consisted of 1923 men and 1968 women who participated in health surveys in the town of Busselton in Western Australia over the period 1966-81. Baseline assessment included cardiovascular risk factor measurement. Mortality follow up to 31 December 1994 was used.

MAIN RESULTS

Risk scores for death from CHD within 10 years based on age, systolic blood pressure, cholesterol, smoking, and BMI were derived from the Busselton study data using logistic regression analysis. Similar risk scores developed from the Framingham, the national health epidemiologic follow up study, and the WHO ERICA cohorts were found to perform just as well in Busselton as the Busselton-derived scores, both before and after controlling the effect of age. There was considerable overlap across the different risk scores in the identification of individuals in the highest quintile of risk. Those in the top 20% of scores included about 41% of deaths from CHD among men and about 63% of deaths from CHD among women.

CONCLUSION

Although there is variation in risk score coefficients across the studies, the relative risk predictive performance of the scores is similar. The use of Framingham and other similar risk scores will not be misleading in white Australian populations.

Dietary management of cardiovascular diseases

Since cholesterol was discovered in atherosclerotic plaques and was able, when given in diet, to induce the same type of lesions in animals, the aim of previous dietary changes was to reduce serum cholesterol as much as possible. For this purpose, the intake of saturated fats was decreased and replaced by linoleic acid, the main fatty acid lowering cholesterol. Nevertheless, this type of diet in primary or secondary prevention did not succeed in reducing satisfactorily cardiovascular and total mortality unless the intake of fish (DART and Hjermann trials) i.e. of n-3 fatty acids, was increased. On the other hand, the diet with the greatest life expectancy in the western world is that of Crete, largely vegetarian with a high intake of alpha-linolenic acid. Such a diet, compared to the usual prudent diet in 600 patients after a first myocardial infarction, reduced within a few months all cause mortality and cardiovascular events by more than 70%. Thus a highly palatable diet adapted from Crete seems to be much more efficient to prevent recurrences and death after a first myocardial infarction than the hypocholesterolemic diet presently advised.