Investigation of the association between angiographically defined coronary artery disease and periodontal disease

Relationship of periodontitis and edentulism to angiographically diagnosed coronary artery disease: A cross-sectional study

OBJECTIVE

The objective of the study is to examine the connection between oral status and the extent of coronary artery disease (CAD), which is diagnosed by angiography.

BACKGROUND

Periodontitis and tooth loss have been linked to atherosclerosis and CAD in previous studies. However, no distinct connection was revealed due to the diversity of the results and the variety of diagnostic methods. To provide a more consistent data pool and stronger evidence, there is a need for studies with standard measurements and diagnostic criteria.

METHODS

309 patients, who consulted to Ankara University, Faculty of Medicine, Department of Cardiology and had coronary angiography, were enrolled to this study. Individuals were grouped based on their coronary angiography results, as CAD (+) (n = 233) and CAD (-) (n = 76). Studied parameters included cardiovascular risk factors, plaque index (PI), remaining teeth count, bleeding on probing (BOP), and probing pocket depth (PPD). Periapical radiographs were taken from teeth with ≥4 mm PPD. Oral status was categorized as periodontally healthy subjects/patients with gingivitis (Group 1), patients with periodontitis (Group 2), and edentulous subjects (Group 3).

RESULTS

PI (P < 0.001), PPD (P = 0.001), BOP (P = 0.004), the number of patients with less than 10 teeth (P = 0.014), and edentulism (P = 0.009) were significantly higher in CAD (+) patients, who were mostly older (P < 0.001) and male (P < 0.001). Multivariate logistic regression analysis revealed that Group 2 (odds ratio = 2.48, 95% confidence interval = 1.24-4.95, P = 0.010) and Group 3 (odds ratio = 2.01, 95% confidence interval = 1.14-5.17, P = 0.040) were highly associated with CAD. Two and three stenosed vessels were significantly higher in Groups 2 and 3 compared to Group 1 (P = 0.003).

CONCLUSIONS

It was found that both edentulism and periodontitis were related to CAD.

A cross-sectional survey to study the relationship of periodontal disease with cardiovascular disease, respiratory disease, and diabetes mellitus

BACKGROUND

Periodontal deterioration has been reported to be associated with systemic diseases such as cardiovascular disease (CVD), diabetes mellitus, respiratory disease, liver cirrhosis, bacterial pneumonia, nutritional deficiencies, and adverse pregnancy outcomes.

AIM

The present study assessed the periodontal disease among patients with systemic conditions such as diabetes, CVD, and respiratory disease.

MATERIALS AND METHODS

The study population consisted of 220 patients each of CVD, respiratory disease, and diabetes mellitus, making a total of 660 patients in the systemic disease group. A control group of 340 subjects were also included in the study for comparison purpose. The periodontal status of the patients with these confirmed medical conditions was assessed using the community periodontal index of treatment needs (CPITNs) index.

RESULTS

The prevalence of CPITN code 4 was found to be greater among the patients with respiratory disease whereas the mean number of sextants with score 4 was found to be greater among the patients with diabetes mellitus and CVD. The treatment need 0 was found to be more among the controls (1.18%) whereas the treatment need 1, 2, and 3 were more among the patients with respiratory disease (100%, 97.73%, and 54.8%), diabetes mellitus (100%, 100% and 46.4%), and CVD (100%, 97.73%, and 38.1%), in comparison to the controls (6.18%).

CONCLUSION

From the findings of the present study, it can be concluded that diabetes mellitus, CVD, and respiratory disease are associated with a higher severity of periodontal disease.

Relationship between periodontal status and C-reactive protein and interleuckin-6 levels among atherosclerotic patients in Bandar Abbas, Iran in 2014

BACKGROUND

Recent studies have reported an association between periodontitis and cardiovascular diseases. Atherosclerosis is also a risk factor for cardiovascular diseases. IL-6 and CRP are important inflammatory markers that are important because they have been shown to be higher when a patient has periodontitis, and they are related to atherosclerosis. The aim of this study was to assess the relationship between periodontitis and CRP and IL-6 in atherosclerotic patients.

METHODS

The study population in this case control study was atherosclerotic patients in Bandar Abbas, Iran in 2014. The participants included 30 individuals with periodontal diseases and 30 individuals without periodontal diseases, and they were allocated into two groups according to probe depth (PD) and clinical attachment loss (CAL). Inflammatory markers, including CRP and IL-6 were measured in the two groups. The data were analyzed using IBM SPSS 21 statistical software. Descriptive statistics, chi-squared, independent samples t-test, and Mann-Whitney tests were used to analyze the data.

RESULTS

Individuals with abnormal CRP had significantly higher PD and CAL than individuals with normal CRP (P<0.001). Although PD was not significantly different in individuals with normal and abnormal IL-6 (P=0.124), CAL was significantly higher in individuals with abnormal IL-6 than in the other individuals (P=0.005).

CONCLUSION

The results of this study showed that CRP and IL-6 are associated with periodontal diseases in atherosclerotic patients. Treatment of periodontal diseases is recommended in atherosclerotic patients.

[The relationship between inflammatory periodontal diseases and cardiovascular diseases]

Estimated the relationship between inflammatory periodontal diseases and the risk of developing cardiovascular disease. Installed combined effect of periodontitis and cardiovascular disease.

Correlation between the severity of periodontitis and coronary artery stenosis in a Chinese population

BACKGROUND

The aim of this study was to evaluate the relationship between the severity of periodontitis and the extent and degree of coronary artery stenosis in a Chinese population.

METHODS

Patients (n = 853) with coronary artery stenosis confirmed by coronary angiography were eligible to take part in the study. Only subjects that were ≥60 years old, had ≥50% stenosis in at least one coronary artery, and did not have diabetes or a history of smoking were included (n = 115). After periodontal examination, including bleeding index, probing depth calculus index, plaque index and periodontal attachment loss, four groups were defined based on the severity of periodontitis: no periodontitis/gingivitis (M0, n = 19); mild periodontitis (M1, n = 27); moderate periodontitis (M2, n = 31); and severe periodontitis (M3, n = 38). The extent and degree of coronary artery stenosis was obtained by calculating the Gensini score (GS).

RESULTS

The GS was significantly greater in the M3 group compared with the M0 group. Multiple linear regression analysis revealed that probing depth and plaque index were significantly correlated with the GS.

CONCLUSIONS

The extent and severity of coronary artery stenosis in Chinese patients ≥60 years old is positively correlated with the severity of periodontitis.

Non-surgical periodontal therapy reduces coronary heart disease risk markers: a randomized controlled trial

AIM

Periodontal disease elevates systemic inflammatory markers strongly associated with coronary heart disease (CHD) risk. The aim of this randomized controlled trial was to investigate the effect of non-surgical periodontal therapy on systemic C-reactive protein (CRP), fibrinogen and white blood cells in CHD patients.

MATERIALS AND METHODS

Angiographically proven CHD patients with periodontitis (n = 317) were randomized to intervention (n = 212) or control group (n = 105). Primary outcome was reduction in serum CRP levels; secondary outcomes were reductions in fibrinogen and white blood cells. Periodontal treatment included scaling, root planing and oral hygiene instructions. Periodontal and systemic parameters were assessed at baseline and at 2-month follow-up. Intent-to-treat (ITT) analysis was performed.

RESULTS

Study was completed by 246 subjects (intervention group = 161; control group = 85). Significant improvements in periodontal and systemic parameters were observed in intervention group. The number of subjects with CRP > 3mg/L in intervention group decreased by 38% and in control group increased by 4%. ITT analysis gave a significant (χ(2) =4.381, p = 0.036) absolute risk reduction of 12.5%.

CONCLUSION

In CHD patients with periodontitis, non-surgical mechanical periodontal therapy significantly reduced systemic levels of C-reactive protein, fibrinogen and white blood cells.

Association of periodontitis with rheumatoid arthritis and atherosclerosis: Novel paradigms in etiopathogeneses and management?

There is increasing documentation of a link between inflammatory periodontal disease affecting the supporting structure of teeth, rheumatoid arthritis, and coronary artery disease. Periodontitis is initiated predominantly by Gram-negative bacteria and progresses as a consequence of the host inflammatory response to periodontal pathogens. Lipopolysaccharide, a cell wall constituent stimulates the production of inflammatory cytokines via the activation of signaling pathways perpetuating inflammatory pathogenesis in a cyclical manner in susceptible individuals; with an element of autoimmune stimulation, not dissimilar to the sequential events seen in RA. Periodontitis, also implicated as a risk factor for cardiovascular disease, promotes mechanisms for atherosclerosis by enhancing an imbalance in systemic inflammatory mediators; more direct mechanisms attributed to microbial products are also implicated in both RA and atherogenesis. Severe periodontal disease characterized by clinical and radiographic parameters has been associated with ischemic stroke risk, significant levels of C-reactive protein and serum amyloid A, amongst others common to both periodontitis and atherosclerosis. Existing data supports the hypothesis that persistent localized infection in periodontitis may influence systemic levels of inflammatory markers and pose a risk for RA and atherosclerosis. A common nucleus of activity in their pathogeneses provides novel paradigms of therapeutic targeting for reciprocal benefit.

The American Journal of Cardiology and Journal of Periodontology editors' consensus: periodontitis and atherosclerotic cardiovascular disease

ACKNOWLEDGMENT

This Editors' Consensus is supported by an educational grant from Colgate-Palmolive, Inc., New York, New York, and is based on a meeting of the authors held in Boston, Massachusetts, on January 9, 2009.

DISCLOSURE

Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Kornman is a full-time employee and shareholder of Interleukin Genetics, Waltham, Massachusetts, which owns patents on genetic biomarkers for chronic inflammatory diseases. Dr. Genco is a consultant to Merck, Whitehouse Station, New Jersey. Dr. Ridker has received research support from AstraZeneca, Wilmington, Delaware; Novartis; Pfizer, New York, New York; Roche, Nutley, New Jersey; Sanofi-Aventis, Bridgewater, New Jersey; and Abbott Laboratories, Abbott Park, Illinois. Dr. Ridker has received non-financial research support from Amgen, Thousand Oaks, California. Dr. Ridker is a co-inventor on patents held by Brigham and Women's Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease. Dr. Ridker is a research consultant for Schering-Plough, Kenilworth, New Jersey; Sanofi-Aventis; AstraZeneca; Isis, Carlsbad, California; Novartis; and Vascular Biogenics, Tel Aviv, Israel. Dr. Van Dyke is a co-inventor on patents held by Boston University, Boston, Massachusetts, that relate to inflammation control, including consulting fees. Dr. Roberts has received honoraria for speaking from Merck, Schering-Plough, AstraZeneca, and Novartis. All other individuals in a position to control content disclosed no relevant financial relationships.

The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: a meta-analysis

BACKGROUND

Previous studies have shown conflicting results as to whether periodontitis (PD) is associated with increased risk of coronary heart disease (CHD). The aim of the current study was to evaluate whether such an association exists.

METHODS

A systematic review of the literature revealed 5 prospective cohort studies (follow-up >6 years), 5 case-control studies, and 5 cross-sectional studies that were eligible for meta-analysis. Individual studies were adjusted for confounding factors such as age, sex, diabetes mellitus, and smoking. The 3 study categories were analyzed separately. Heterogeneity of the studies was assessed by Cochran Q test. The studies were homogeneous; therefore, the Mantel-Haenszel fixed-effect model was used to compute common relative risk and odds ratio (OR).

RESULTS

Meta-analysis of the 5 prospective cohort studies (86092 patients) indicated that individuals with PD had a 1.14 times higher risk of developing CHD than the controls (relative risk 1.14, 95% CI 1.074-1.213, P < .001). The case-control studies (1423 patients) showed an even greater risk of developing CHD (OR 2.22, 95% CI 1.59-3.117, P < .001). The prevalence of CHD in the cross-sectional studies (17724 patients) was significantly greater among individuals with PD than in those without PD (OR 1.59, 95% CI 1.329-1.907, P < .001). When the relationship between number of teeth and incidence of CHD was analyzed, cohort studies showed 1.24 times increased risk (95% CI 1.14-1.36, P < .0001) of development of CHD in patients with <10 teeth.

CONCLUSIONS

This meta-analysis indicates that both the prevalence and incidence of CHD are significantly increased in PD. Therefore, PD may be a risk factor for CHD. Prospective studies are required to prove this assumption and evaluate risk reduction with the treatment of PD.

Chronic inflammatory autoimmune disorders and atherosclerosis

Rheumatoid arthritis (RA), periodontal disease (PD), and coronary artery disease (CAD) are common chronic inflammatory diseases. RA is associated with accelerated vascular risk resulting in an increased prevalence of CAD with attendant early mortality and excess morbidity. RA and PD have a common pathobiology. Accordingly, the aim of this study was to evaluate the association between RA, PD, and CAD and the influence of systemic inflammatory factors. A total of 100 active RA patients of which 50 had established CAD and 50 had no CAD were assessed for PD. All subjects underwent a clinical, cardiac, dental, laboratory, and radiological evaluation. Blood samples were obtained and the level of high-sensitivity C-reactive protein (hs-CRP), total white blood counts (WBC), erythrocyte sedimentation rate (ESR), fibrinogen and tumor necrosis alpha (TNF-alpha), total cholesterol (TC), and high-density lipoprotein (HDL) were assayed. The findings of this study demonstrated an association between RA, PD, and CAD. The RA patients with CAD had significantly more PD than RA patients without CAD, P < 0.001. The inflammatory markers hs-CRP, ESR, WBC, fibrinogen, and TNF-alpha were raised in all patients but were significantly higher in RA patients with CAD who also had PD, that is, in those with more inflammatory disease burden. HDL levels were lower in RA patients with CAD when compared to RA patients without CAD, P < 0.005. Evidence from this study shows an association between RA, PD, CAD, and systemic levels of the inflammatory mediators. The implication is that inflammation may be the central link between the chronic inflammatory autoimmune disorders and atherosclerosis.

Rheumatoid arthritis, periodontal disease and coronary artery disease

Rheumatoid arthritis (RA), periodontal disease (PD), and coronary artery disease (CAD) are common chronic inflammatory diseases. RA is associated with accelerated vascular risk resulting in an increased prevalence of CAD with attendant early mortality and excess morbidity. RA and PD have a common pathobiology. Accordingly, the aim of this study was to evaluate the association between RA, PD, and CAD and the influence of systemic inflammatory factors. A total of 100 active RA patients of which 50 had established CAD and 50 had no CAD were assessed for PD. All subjects underwent a clinical, cardiac, dental, laboratory, and radiological evaluation. Blood samples were obtained, and the level of high sensitivity C-reactive protein (hs-CRP), total white blood counts (WBC), erythrocyte sedimentation rate (ESR), fibrinogen and tumor necrosis factor (TNF) alpha, total cholesterol (TC), and high density lipoprotein (HDL) were assayed. The findings of this study demonstrated an association between RA, PD, and CAD. The RA patients with CAD had significantly more PD than RA patients without CAD. The inflammatory markers, hsCRP, ESR, WBC, fibrinogen, and TNF-alpha, were raised in all patients but were significantly higher in RA patients with CAD who also had PD. HDL levels were lower in RA patients with CAD when compared to RA patients without CAD. Evidence from this study shows an association between RA, PD, CAD, and systemic levels of the inflammatory mediators. The implication is that inflammation may be the central link between the chronic inflammatory, autoimmune disorders, and atherosclerosis.

Periodontal Destruction Is Associated With Coronary Artery Disease and Periodontal Infection With Acute Coronary Syndrome

BACKGROUND

Coronary artery disease (CAD) is a highly prevalent disease with significant morbidity and mortality. Periodontal disease has been suggested to influence this disease and has been associated with CAD in some epidemiologic studies. However, this relation is still controversial. This study aimed to determine the relationship between periodontal disease measures and CAD and acute coronary syndromes (ACSs).

METHODS

Two hundred one patients presenting with stable angina or ACS referred for coronary angiography underwent a periodontal assessment including evaluation of periodontal pathogens. Severity of CAD was determined by the number of obstructed coronary arteries.

RESULTS

Patients with severe CAD defined by multiple vessel disease had significantly more periodontal destruction than those with mild CAD, as shown by mean clinical attachment level, a measure of chronic periodontal disease (CAL; 5.43 +/- 1.8 versus 4.85 +/- 1.6; P = 0.02), percentage of teeth with CAL >or=5 mm (82.1 +/- 23.4 versus 70.4 +/- 26.9; P = 0.002), and number of missing teeth (8.75 +/- 6.6 versus 6.76 +/- 6.6; P = 0.03). Logistic regression analysis showed that percentage of teeth with CAL >or=5 mm was significantly associated with CAD severity. Patients with ACS had significantly higher plaque scores, gingival index, and Porphyromonas gingivalis counts than stable patients. Logistic regression analysis showed that either plaque score or percentage of P. gingivalis was significantly associated with ACS.

CONCLUSION

Periodontal destruction measures are significantly correlated with CAD severity, whereas periodontal infectious measures are significantly associated with clinical cardiac status.

Angiographically confirmed coronary heart disease and periodontal disease in middle-aged males

BACKGROUND

The aim of this study was to investigate whether an association could be demonstrated between coronary heart disease (CHD) and chronic periodontitis in a population of middle-aged males in Northern Ireland.

METHODS

A case-control design was used. Cases were men aged over 40 years with angiographically proven CHD. Controls were age-matched males, with no evidence of CHD, randomly drawn from the same locality as the cases. Each subject had a clinical periodontal examination and completed a detailed sociodemographic questionnaire. High sensitivity C-reactive protein (CRP) was measured in serum by immunoturbidimetry.

RESULTS

There were 92 cases (mean age 56.7 years; SD = 6.3) and 79 controls (mean age 58.2 years; SD = 6.7). The CHD cases had an average of three teeth less than the controls (P <0.0001). A higher proportion of sites examined in cases than controls had plaque (P = 0.004), bleeding on probing (P = 0.013), and probing depths of > or = 4 mm (P = 0.006) or > or = 6 mm (P = 0.03). Subjects with > or = 4 mm pocketing in more than 20% of their interproximal sites and those with deep pocketing (> or = 6 mm) were classified as having poor periodontal status. A total of 35 cases (38%), compared to only 13 controls (16%), had a poor periodontal status (P = 0.0017). Men with a poor periodontal condition had higher levels of CRP (median 2.19 mg/l) than those with good periodontal health (median 1.42 mg/l), P = 0.007. After adjusting for smoking, academic achievement, alcohol consumption, unemployment, ability to maintain body weight, regular exercise, ability to relax daily, having a hobby or pastime, plaque, and CRP, logistic regression analysis showed that poor periodontal status was significantly associated with CHD, with an adjusted odds ratio of 3.06 and 95% confidence intervals of 1.02 to 9.17, P = 0.046.

CONCLUSIONS

There was an association between coronary heart disease and poor periodontal status in the middle-aged males investigated. This association was independent of diabetes and all other cardiovascular risk factors investigated.

Tooth loss is independently associated with the risk of acquired aortic valve sclerosis

BACKGROUND

Several studies have shown that periodontal disease and atherosclerosis are associated. Aortic valve sclerosis (AVS) represents the sum of processes that are similar to the development of atherosclerosis. The present analysis was performed to investigate associations between periodontal disease, tooth loss, and AVS.

METHODS

The population-based SHIP was conducted in northeast Germany. A study population of 2341 individuals aged > or =45 years was available for the present analysis. Aortic valve sclerosis was determined by echocardiography. Periodontal status was assessed by attachment loss and tooth loss.

RESULTS

The prevalence of AVS was 29.9%. Logistic regression analyses did not reveal attachment loss as an independent risk factor for AVS. However, a reduced number of teeth was independently associated with AVS. Other risk factors for AVS were age, history of myocardial infarction, body mass index, pulse pressure, plasma fibrinogen and lipoprotein (a) levels, and the use of drugs that act on the renin-angiotensin system.

CONCLUSION

A reduced number of teeth was independently associated with the risk of AVS. This finding further strengthens the link between oral health and cardiovascular disorders.

[Discoloration of gingiva in the presence of fixed dental restorations]

AIM

To investigate the frequency of discoloration of gingiva in the presence of fixed dental restorations, regarding the type of alloy of which restorations were made, and to show histopathological changes of discolored gingiva.

METHODS

One hundred and eighty four patients of both sexes were examined. The average age of the examinees was 52. They were divided into four groups according to the alloys from which their restorations were made. Standardized history questionnaires and clinical examination procedures were developed for this study. In ten examinees, whose teeth were indicated for extraction and who had a discoloration of gingiva, the samples of tissue were taken from the discolored gingiva for histopathological examination.

RESULTS

Our results showed the presence of discolored gingiva in all four groups. It was most frequent in the examinees with fixed restorations made of Ni-Cr alloy (43,5%) and less frequent in those with fixed dental restorations made of gold alloy (26,5%). Histopathological examination showed the presence of tissue foreign body granulomas with giant cells in which the metal particles were found, partially as small and partially as large particles.

CONCLUSION

Results suggested that grayish discoloration of gingiva was present in all four groups of examinees. The highest number of examinees with discolored gingiva was in the group with restorations made of Ni-Cr alloy. Grayish discoloration of gingiva was a consequence of incorporation of metal particles into gingival tissue.

Oral health, atherosclerosis, and cardiovascular disease

During the last two decades, there has been an increasing interest in the impact of oral health on atherosclerosis and subsequent cardiovascular disease (CVD). The advent of the inflammation paradigm in coronary pathogenesis stimulated research in chronic infections caused by a variety of micro-organisms-such as Chlamydia pneumoniae, Helicobacter pylori, and cytomegalovirus-as well as dental pathogens, since these chronic infections are thought to be involved in the etiopathogenesis of CVD by releasing cytokines and other pro-inflammatory mediators (e.g., C-reactive protein [CRP], tumor necrosis factor [TNF-alpha]) that may initiate a cascade of biochemical reactions and cause endothelial damage and facilitate cholesterol plaque attachment. Yet, due to the multi-factorial nature of dental infection and CVD, confirming a causal association is difficult, and the published results are conflicting. The main deficit in the majority of these studies has been the inadequate control of numerous confounding factors, leading to an overestimation and the imprecise measurement of the predictor or overadjustment of the confounding variables, resulting in underestimation of the risks. A meta-analysis of prospective and retrospective follow-up studies has shown that periodontal disease may increase the risk of CVD by approximately 20% (95% confidence interval [CI], 1.08-1.32). Similarly, the reported risk ratio between periodontal disease and stroke is even stronger, varying from 2.85 (CI 1.78-4.56) to 1.74 (CI 1.08-2.81). The association between peripheral vascular disease and oral health parameters has been explored in only two studies, and the resultant relative risks among individuals with periodontitis were 1.41 (CI 1.12-1.77) and 2.27 (CI 1.32-3.90), respectively. Overall, it appears that periodontal disease may indeed contribute to the pathogenesis of cardiovascular disease, although the statistical effect size is small.

Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review

BACKGROUND

Recent studies implicate exposure to systemic conditions involving chronic inflammation, including chronic periodontitis, in the etiology of atherosclerosis.

RATIONALE

A systematic review of the literature was conducted to assess the association between chronic inflammatory periodontal disease and atherosclerosis.

FOCUSED QUESTION

Does periodontal disease influence the initiation/progression of atherosclerosis and, therefore, cardiovascular disease (CVD), stroke, and peripheral vascular disease (PVD)?

SEARCH PROTOCOL

MEDLINE, pre-MEDLINE, MEDLINE Daily Update, and the Cochrane Controlled Trials Register were searched to identify human studies that related variables associated with atherosclerosis to periodontal disease. Searches were made for papers published from 1966 through March 2002.

INCLUSION CRITERIA

Published randomized controlled clinical trials (RCTs), longitudinal, cohort, and case-control studies were included. Study participants included those with atherosclerosis, myocardial infarction (MI), stroke, or PVD. Oral conditions included periodontal disease.

EXCLUSION CRITERIA

Only studies on humans were included.

DATA COLLECTION AND ANALYSIS

Because the studies used different oral assessment measures, it was not possible to perform a meta-analysis of the data reported. Weighted mean differences, relative risks, or odds ratios were compared for cohort studies.

MAIN RESULTS

1. Of the initial 1,526 studies identified, 31 (including 8 case-control and 18 cross-sectional reports) were included in the analysis. Taken together, most of the literature supports a modest association between periodontal disease and atherosclerosis. However, data reported in several studies do not show this association. 2. The absence of a standard definition and measures for periodontal disease complicates interpretation of results, as do potential confounding risk factors common to both conditions.

REVIEWERS' CONCLUSIONS

1. Periodontal disease may be modestly associated with atherosclerosis, MI, and CVD. 2. Additional large-scale longitudinal epidemiologic and intervention studies are necessary to validate this association and to determine causality.