The association of the Mediterranean Adequacy Index with fatal coronary events in an Italian middle-aged male population followed for 40 years

BACKGROUND AND AIMS

The dietary habits defined as the Mediterranean diet have shown to be protective for coronary heart disease (CHD) and other morbid conditions. The present analysis aims to test the Mediterranean Adequacy Index (MAI), a dietary index derived from the Mediterranean habits, versus the occurrence of fatal CHD events in an Italian male population followed for 40 years.

METHODS AND RESULTS

In 1965, at the time of the 5-year follow-up examination of the Italian Rural Areas of the Seven Countries Study, the diet was assessed by the dietary-history method in 1139 men aged 45-64 years, free from previous coronary events, in the rural communities of Crevalcore (Northern Italy) and Montegiorgio (Central Italy). MAI has been computed and its natural log (lnMAI) used for the analysis. Mortality data were collected and coded for the subsequent 40 years. The lnMAI was inversely associated with CHD mortality at 20 and 40 years when entered alone in the Cox proportional hazards model and when adjusted for age, cigarette smoking, systolic blood pressure, serum cholesterol, physical activity and body mass index. The hazard ratio for 1 unit of lnMAI (roughly corresponding to 2.7 units of MAI) was associated with a CHD mortality reduction of 26% in 20 years and 21% in 40 years of follow-up, when adjusted for the covariates.

CONCLUSIONS

In an Italian middle-aged male population, MAI showed the protective effect of a healthy Mediterranean Diet pattern versus the occurrence of fatal CHD events at 20 and 40 years.

Gingival Myofibroma. A case report

AIM

The Myofibroma (MF) is a benign mesenchymal tumor frequently observed in the skin and subcutaneous tissue of the head-neck region. It is described mainly in infants with congenital forms and, in early childhood, with acquired forms. Less often, it can be observed in adolescents and adults. The location of a MF in the oral cavity is occasional and differential diagnosis must be established with other benign and malignant neoplasms, high or low grade, of the oral mucosa. The histology of the myofibroma shows a biphasic growth pattern: elongated spindle cells with eosinophilic cytoplasm, in the borders, polygonal cells arranged in a palisading pattern, with hyperchromatic nuclei, in the central portions. The diagnosis of MF, usually made after excision of the neoformation, is obtained by means of immunohistochemistry, in which there is positivity for vimentin and αactine smooth muscle antibodies and negativity for keratin, S-100, EMA (Epithelial Membrane Antigen) antibodies. The treatment is surgical; the prognosis is generally good with low rates of recurrence after excision.

CASE REPORT

The authors describe a case of MF in a 16-year-old male subject, that came to their observation for the growth of a considerable mass attached to the gingival mucosa, describing the therapeutic strategy.

Secondary osteoporosis in men and women: clinical challenge of an unresolved issue

OBJECTIVE

To evaluate the clinical and etiological factors of osteoporosis. We also tested the FRAX algorithm to compare the assessment of fracture risk in patients with primary or secondary osteoporosis.

METHODS

A prospective study carried out in a large sample of 123 men and 246 women. All subjects had a biochemical, densitometric, and radiological examination of thoracic and lumbar spine.

RESULTS

The prevalence of primary (men 52.9% vs women 50%; p = nonsignificant) and secondary (men 21.1% vs women 17.5%; p = nonsignificant) osteoporosis did not differ between the sexes. In contrast, the prevalence of primary osteoporosis was significantly higher than secondary causes (p < 0.0001) in both men and women. While women came to our attention for prevention of osteoporosis, men sought help because of clinical symptoms or disease-related complications, such as fractures. As evaluated by the FRAX tool, patients with osteopenia do not need treatment, in agreement with Italian guidelines. The estimated risk of major osteoporotic and hip fractures was significantly higher in women with secondary osteoporosis compared to men and also compared to women with primary osteoporosis.

CONCLUSION

The prevalence of secondary osteoporosis in men is similar to that in women and it is less frequent than commonly reported. In patients with secondary osteoporosis, FRAX calculation may provide an estimate of a particularly high fracture risk in patients whose bone fragility is usually attributed to another disease.

Testicular metastasis of signet ring cell tumour of unknown origin: diagnostic features of a tricky case

We introduce the diagnostic complexity of a testicular metastasis by signet ring cell adenocarcinoma of unknown origin. Testicular metastases are a rare event but, particular after 50 years of age, a testicular mass could represent a metastasis.

Sleep-disordered breathing in a sample of 495 children in Southern Italy

AIM

Our objective was to investigate the occurrence of sleep-related breathing disturbances in a large cohort of school-aged children in Southern Italy, and to evaluate the association with anthropometric data and clinical findings of oropharynx and nasal airways.

STUDY DESIGN

A two-phase cross-sectional study was conducted with children from schools in Turi, Italy.

MATERIALS AND METHODS

A screening phase aimed to identify symptomatic children and clinical data from a cohort of 495 children by a self-administered questionnaire, and an instrumental phase for the definition of sleep-related disorders and clinical analysis of oral status were performed. According to the answers, children were classified into 3 groups: habitual snorers, occasional snorers, and non-snorers. All habitual snoring children underwent a polysomnographic home evaluation, and those with oxygen desaturation index (ODI) > 2 were considered for nocturnal polygraphic monitoring (NPM). Children with apnoea/ hypopnea index (AHI) > 3 received a diagnosis of obstructive sleep apnoea syndrome (OSAS). Moreover, a complete oral examination was performed.

RESULTS

A total of 436 questionnaires (response rate: 88.08%) were returned and scored (202 M, 234 F; Mean age ± Standard deviation: 6.2 ± 1.8); 18 children (4%) were identified as habitual snorers, 140 children (32%) were identified as occasional snorers, and 278 children (64%) were identified as non-snorers. The percentage of female children who were habitual snorers was higher than the percentage of male children (4.7% vs 3.6%). Habitual snorers had significantly more nighttime symptoms. OSAS was diagnosed in 2 children by NPM. A statistically significant association between snoring, cross-bite, open-bite and increased over-jet was found.

CONCLUSION

Habitual snoring and OSAS are significant problems for children and may be associated with diurnal symptoms. The presence of malocclusion increases the likelihood of sleep-related breathing disturbances.

An interdisciplinary approach to a survey on dental caries in a group of 3-year-olds in Ascoli Piceno (Italy)

AIM

The purpose of this study was to investigate the dental caries experience in a group of 3-year-old children, through an interdisciplinary protocol, both paediatric and paedodontic, in the district of Ascoli Piceno (Marche, Italy).

MATERIALS AND METHODS

A sample of 82 children, 38 males and 44 females, was recruited by four paediatricians during a preliminary study phase, which consisted of the epidemiological survey explanation to the involved children's parents and informed consents collection; the survey was first planned and then performed by one calibrated examiner, (Cohen k test was 0.85) in two days on May 2008. The examinations were performed in the nurseries of the schools attended by the children. The collected data were analysed by descriptive and association statistics: the chi² test was used to investigate the association between caries and gender, assuming as statistical significance level the p < 0.05 value.

RESULTS

The study revealed that caries prevalence in the observed population was 38%, while caries free group accounted for 61%; the mean dmft was 1.06, with a standard deviation of 1.64. No statistical significance was observed in the association between caries and gender (chi²=0.65, p > 0.05). discussion: Dental caries prevalence of the surveyed population, according to the WHO 2010 objectives, was judged quite high, focusing the low caries free group (61% instead of 90% or over) and the children's preschool age; nonetheless the sample situation was not considered as critical, because the WHO 2000 goals were achieved (caries free > 50%).

CONCLUSION

The interdisciplinary paedodontic paediatric protocol, used in the present study, was a useful and powerful instrument for preparing the epidemiological survey and could be the basis of future preventive programs.

Biochemical markers in glucocorticoid-induced osteoporosis

Following the introduction of corticosteroids as therapeutic agents in the 1950s, their use has been expanded so that today glucocorticoids are widely used. There are few studies in the literature directly aimed at describing the changes of bone markers following glucocorticoid administration. The interpretation of some of these investigations may be hampered by a number of confounding factors, whose influence is not always taken into consideration. In general, the effects of glucocorticoid administration are represented by a reduction in bone formation markers (particularly considering serum osteocalcin levels) and a trend to an increase or no change in bone resorption markers. The inconsistency of this last finding may be related to the time at which the observation is carried out and to the marker employed.

Well-differentiated giant scrotal liposarcoma: case presentation and management

Scrotal liposarcoma is an uncommon disease, usually found after the fifth decade. We describe the case of a well-differentiated scrotal liposarcoma associated with a considerable inflammatory reaction, treated with surgical ablation.

Oral hygiene habits and attitudes in a school population in L'Aquila (Italy)

AIM

This study aims to analyse the results of a questionnaire submitted to students of the elementary schools in L'Aquila in order to understand their awareness of a correct caries prevention method by using fluoride.

MATERIALS AND METHODS

4th and 5th grade students of elementary schools in L'Aquila were submitted to a questionnaire; from a total of 1205 students, age ranging from 8 to 12, 1094 were questioned; 7 children 8 years old, 282 of 9, 555 of 10, 243 of 11, 8 of 12, and only 2 of 13, respectively (the last 2 were registered later at school because non-EU citizens).

RESULTS

Among the Italian population with a low incidence of dental decay, a relatively limited group, called 'high risk decay group', revealed a higher incidence of the pathology than the standard one.

CONCLUSION

In a multiracial society, as ours, it is important to carry out an effective screening in order to recognize different categories of patients through simple questions inserted in the patient's case history.

Comparison of three different dietary scores in relation to 10-year mortality in elderly European subjects: the HALE project

OBJECTIVE

To investigate and compare the associations between dietary patterns and mortality using different European indexes of overall dietary quality.

DESIGN, SETTING AND PARTICIPANTS

The HALE (Healthy Ageing: a Longitudinal study in Europe) population includes 2,068 men and 1,049 women, aged between 70 and 90 years of 10 European countries. Subjects were followed for 10 years. This cohort study was conducted between 1988 and 2000.

RESULTS

During the follow-up period, 1,382 people died. The Mediterranean Diet Score (MDS) (HR: 0.82 with 95% CI: 0.75-0.91), the Mediterranean Adequacy Index (MDI) (HR: 0.83 with 95% CI: 0.75-0.92) and the Healthy Diet Indicator (HDI)(HR: 0.89 with 95% CI: 0.81-0.98) were inversely associated with all-causes mortality. Adjustments were made for age, gender, alcohol consumption, physical activity, smoking, number of years of education, body mass index, chronic diseases at baseline and study centre.

CONCLUSIONS

The MDS, the MDI and the HDI were significantly inversely related with mortality.

SPONSORSHIP

This study is based on data of the HALE project and supported by a grant from the European Union (QLK6-CT-2000-00211) to D Kromhout.

Mediterranean Adequacy Index: correlation with 25-year mortality from coronary heart disease in the Seven Countries Study

BACKGROUND AND AIM

The Mediterranean Adequacy Index (MAI) is an overall indicator characterising a diet in comparison with a Reference Mediterranean Diet. We computed the MAI of random samples of men surveyed for their eating habits in the 16 cohorts of the Seven Countries Study, and found that it inversely correlated with the 25-year death rates from coronary heart disease in the 16 cohorts (R = -0.72; p = 0.001). The correlation coefficient was -0.84 (p < 0.001) when the MAI was converted into natural logarithms.

CONCLUSIONS

These findings once again support the association between typical Mediterranean eating habits and protection against coronary heart disease.

Body fat in adult man: semicentenary of fat density and skinfolds

Several studies carried out in the last 50 years on body fat in adult man are reported. Firstly, the terminology is clarified, then the new values of the density of fat extracted from adipose tissue from human and some laboratory and domestic animals are presented. The density of subcutaneous and visceral fat of five human subjects is 900 kg/m(3) at 37 degrees C. A few of the drawbacks of the densitometric method for human body composition analysis are described. Finally, the first appropriate calipers for skinfold thickness measurement are illustrated, i. e., the adaptation of Glogau's Vernier caliper, the improved Best caliper, and the Meikosha caliper. Comparisons of measurements of triceps and subscapular skinfolds obtained with these calipers are reported.

Trace element intake and status of Italian subjects living in the Gubbio area

Daily intakes of certain trace elements (Pb, Cd, Ni, Hg, and Cr) were assessed using dietary history and weighed record methods and concurrent chemical analysis (CA) of duplicate portions, along with blood levels, in a group (21 M, 23 F) of inhabitants of the Gubbio area (Belvedere, Biscina, Scritto). The evaluation of only intake of trace elements was accomplished in 40 subjects (20 M, 20 F) 1 year later. In both surveys, trace element intakes were generally lower than the potential tolerable weekly intake. However, daily intakes of Pb, Cd, Ni, Hg, and Cr were higher in men compared to women in both surveys (P<0.05). In fact, intakes at the 50th percentile were greater in men by approximately 75% for Pb, 91% for Cd, 20% for Ni, 45% for Hg, and 29% for Cr in the first survey. In the second survey, percentage differences for Pb, Cd, Ni, and Cr were about 12%, 28%, 26%, and 26%, respectively. Blood trace element levels were slightly higher in men in the first survey. Interestingly, no correlation was observed between the intake of trace elements and corresponding blood values. Food basket and total diet, which were computed from the weighed record method for 2 days, showed relevant disagreements with CA of duplicate portion. Moreover, the comparison in content of Pb, Cd, Ni, and Cr obtained by CA of cooked dishes or by calculation using values of raw foods showed significant differences (P<0.05). It was concluded that trace element intake should be assessed by CA of duplicate portion.

Validation of the Italian food composition database of the European institute of oncology

OBJECTIVE

To compare nutrient intakes obtained by chemical analysis of food composite or duplicate portion of diets with those obtained by weighed record method using the database of the European Institute of Oncology (EIO).

SETTING

Nutrition Section, Department of Internal Medicine, University of Perugia, Italy.

SUBJECTS

Fifteen subjects aged 40-59 y in 1960 (41 observations in three seasons), twenty-six subjects in 1965, and only nine remaining subjects in 1970 and 1991 were examined in Crevalcore. In Montegiorgio sixteen subjects aged 40-59 y in 1960 (39 observations in three seasons), thirty-two in 1965, twenty in 1970 and nine in 1991 were assessed. Forty-four subjects in Gubbio area (Biscina, Belvedere and Scritto; 21 males, 23 females; age 56.2+/-14.4 y) were evaluated in 1993 and 1994.

METHODS

For dietary appraisal the individual weighed record method was used for 7, 3 or 2 days. Equivalent food composites were made up from local foodstuffs and the duplicate portions were chemically analysed for total nitrogen, fat, saturated and polyunsaturated fatty acids, carbohydrates, retinol, beta-carotene, thiamin and riboflavin.

RESULTS

In Crevalcore, a significant difference for protein intake was found between analysis and calculation with EIO database in 1965 and 1991 (P<0.05). Fat intake was significant different for EIO database compared to analysis in 1965 survey (P<0.05), but not for other years. In Montegiorgio, there was a significant difference for protein intake between analysis and calculation with EIO database in 1970 and 1991 (both P<0.001). EIO database showed a significant difference in regard to analysis for fat intake in 1960 IV, 1965, 1970 and 1991 (P<0.05). In both areas there was a significant difference between analysis and EIO database for starch and fibre, but not for polyunsaturated fatty acids and soluble carbohydrates (all P<0.05). In Gubbio area, a significant difference was found between analysis and calculation with EIO database for fat, retinol, beta-carotene and riboflavin intakes (all P<0.05).

CONCLUSIONS

According to previous and present studies food composition tables and databases, such as the EIO database, cannot be considered a reliable method to determine nutrient intakes, particularly for some vitamins.

Diet and 20-year chronic obstructive pulmonary disease mortality in middle-aged men from three European countries

OBJECTIVE

To investigate the relation of baseline antioxidant, fruit, vegetable and fish intake with 20 y chronic obstructive pulmonary disease (COPD) mortality in middle-aged men from three European countries.

DESIGN

Prospective study (1970-1990).

SETTING

Five population-based cohorts of middle-aged men from Finland, Italy and The Netherlands.

SUBJECTS

A total of 2917 men aged 50-69 y at baseline.

METHODS

Baseline information on diet was collected using the cross-check dietary history method. After 20 y of follow-up the underlying cause of death of those who died was established centrally. Survival analyses were performed using the Cox Proportional Hazards Model.

RESULTS

After adjustment for age, smoking and country, we observed an inverse trend (P-trend <0.05) of 20 y COPD mortality across tertiles of fruit and vitamin E intake. No trend was observed for vegetables, fish, vitamin C and beta-carotene. When modelled continuously, a 100 g increase in fruit intake was associated with a 24% lower COPD mortality risk (RR=0.76, 95% CI=0.60-0.92). For vitamin E intake (per 5 mg) the RR was 0.77 (95% CI=0.55-1.06), after adjustment for age, smoking and country. Additional adjustment for body mass index, total energy intake and alcohol consumption reduced the RR to 0.86 (95% CI=0.69-1.07, P=0.12) for fruit and 0.93 (95% CI=0.65-1.33) for vitamin E.

CONCLUSIONS

Our results suggest a protective effect of fruit and possibly vitamin E intake against COPD. No effect was observed for intake of vitamin C, beta-carotene, vegetables and fish.

Alcohol consumption in relation to 20-year COPD mortality and pulmonary function in middle-aged men from three European countries

Alcohol consumption shows a U-shaped relation with all-cause and cardiovascular mortality. To determine whether a similar relation exists between alcohol and chronic obstructive pulmonary disease mortality, we analyzed data on alcohol consumption in 1970 and 20-year mortality from chronic obstructive pulmonary disease among 2,953 middle-aged men from Finland, Italy, and the Netherlands. We also studied alcohol consumption in relation to pulmonary function (FEV1 or FEV0.75) at baseline. We used regression models adjusted for age, height (for pulmonary function only), body mass index, smoking habits, energy intake, and country. A smoothed spline-plot showed a U-shaped relation between alcohol and chronic obstructive pulmonary disease mortality. Compared with non-drinkers and occasional drinkers, the relative risk of chronic obstructive pulmonary disease mortality was 0.60 (95% CI = 0.33-1.09) in light drinkers (> 1 drink per week, < or = 3 drinks per day) and 1.25 (95% CI = 0.47-3.31) in moderate-to-heavy drinkers. Pulmonary function was lower in non-drinkers compared with occasional and light drinkers in Finland (75 ml, 95% CI = -2 to 151) and the Netherlands (93 ml, 95% CI = 0-186) and lower in very heavy (> 12 drinks per day) compared with moderate-to-heavy drinkers in Italy (99 ml, 95% CI = 9-189). In conclusion, we observed a U-shaped curve between alcohol consumption and 20-year chronic obstructive pulmonary disease mortality in middle-aged men that was supported by cross-sectional data on alcohol and pulmonary function.

Cohort analysis of fruit and vegetable consumption and lung cancer mortality in European men

Our aim was to examine the relationship between fruit and vegetable consumption and lung cancer mortality in a cohort of European males. Around 1970, dietary intake of Finnish, Italian and Dutch middle-aged men was assessed using a cross-check dietary history. Complete baseline information was available for 3,108 men, of whom 1,578 were baseline smokers. We used Cox proportional hazard analyses to calculate risk estimates for the consumption in country-specific tertiles on lung cancer in smokers. During 25 years of follow-up, 149 lung cancer deaths occurred in the smokers. Fruit consumption was inversely associated with lung cancer mortality among smokers; compared with the lowest, adjusted RRs for the intermediate and highest tertiles were 0.56 (0.37-0.84) and 0.69 (0.46-1.02), p-trend 0.05. Only in the Dutch cohort was this association statistically significant [adjusted relative risks (RRs) 1.00, 0.33 (0.16-0.70) and 0.35 (0.16-0.74), p-trend 0.004]. In Finland lung cancer risk was lower with higher fruit intake but not significantly, whereas in Italy no association was observed. Stratifying on cigarette smoking intensity (non, light and heavy) revealed an inverse association in the heavy smokers only [adjusted RRs (95% confidence intervals [CI]) 1; 0.47 (0.26-0.84); 0.40 (0.20-0.78)). Vegetable consumption was not related to lung cancer risk in smokers. However, analyses stratified on cigarette smoking intensity gave some indication for a lower lung cancer risk with higher intake. In conclusion, in this prospective analysis among European smoking men, fruit intake was inversely related to lung cancer mortality. This association was confined to heavy cigarette smokers.

Role of smoking and diet in the cross-cultural variation in lung-cancer mortality: the Seven Countries Study. Seven Countries Study Research Group

We examined the role of smoking and diet in the cross-cultural variation in lung-cancer mortality, using aggregated data of the Seven Countries Study, a follow-up study comprising 12,763 middle-aged men in 16 cohorts in Europe, the United States and Japan, which started around 1960. Smoking habits were assessed with a standardised questionnaire. Dietary intake was collected in random sub-samples of each cohort by the dietary record method. Cohort-specific 25-year lung-cancer mortality among all men and among categories of smoking behaviour was related to smoking prevalence and population average dietary intake, respectively, using Poisson regression. Smoking prevalence was positively associated with lung-cancer mortality [risk ratio 1.47, 95% confidence interval (CI) 1.05-2.07, for an increase of 10 percentage points]. Lung-cancer mortality among smokers, which varied significantly among cultures, was positively associated with average fat intake, especially saturated fat intake (rate ratio 1.10, 95% CI 1.04-1.17, for an increase of 4.6 g) but not with unsaturated fat intake. Average fruit and vegetable intake were not related to lung-cancer mortality. Among never-smokers, the power to detect associations was low. In conclusion, both smoking prevalence and average fat intake, especially saturated fat, may play a role in the cross-cultural variation in lung-cancer mortality, either independently or by effect modification.

Relationship of some risk factors with typical and atypical manifestations of coronary heart disease

BACKGROUND

This analysis explores whether 'typical' clinical manifestations of coronary heart disease (CHD) such as myocardial infarction and sudden death, relate to major cardiovascular risk factors in the same way as the 'atypical' manifestations, e.g. heart failure and chronic arrhythmias.

PATIENTS AND METHODS

Sixteen cohorts of men aged 40-59 in seven countries were examined, risk factors measured (age, systolic blood pressure, serum cholesterol and smoking habits) and 25-year mortality data collected in a systematic way. Cohorts were located in the US (n = 1), Finland (n = 2), the Netherlands (n = 1), Italy (n = 3), former Yugoslavia (n = 5), Greece (n = 2) and Japan (n = 2), with a total of 12,763 individuals. Ecological analysis based on regression equations and correlation among cohorts, and individual analyses based on proportional hazard models in pools of cohorts were conducted with typical and atypical CHD deaths as dependent variables.

RESULTS

The ecological analysis suggests a significant relationship of populational mean levels of serum cholesterol and of systolic blood pressure to age-adjusted death rates from typical CHD manifestations. The relationships for atypical CHD deaths were not statistically significant. In the ecological approach with multivariate analysis, none of the risk factors showed relevant associations with event rates, except serum cholesterol and typical CHD deaths. The ecological relationship of serum cholesterol to atypical CHD death rates was negative but not significant. On average, mean age at death was statistically higher among atypical CHD than typical CHD patients (70.2 vs. 65.8 years). In the individual multivariate analysis conducted on pools of countries, the relationship of risk factors with typical CHD deaths was direct and significant for age, systolic blood pressure, and smoking habits in Northern Europe and America and Southern Europe, but only for systolic blood pressure and smoking habits in Japan, whereas for atypical CHD, the predictive factors were age, systolic blood pressure and cigarette smoking in Northern Europe and America and Southern Europe, but only age in Japan.

CONCLUSIONS

The usual relationship of blood pressure and smoking habits and the differential relationship of serum cholesterol with atypical CHD (negative or absent) versus typical CHD (direct and significant) could be explained by 'two different diseases' or by a mix of poorly classified conditions among the atypical cases.

Alcohol and survival in the Italian rural cohorts of the Seven Countries Study

BACKGROUND

Middle-aged men who regularly drink a moderate amount of alcohol have lower mortality rates from all causes in comparison with abstainers and heavy drinkers. This cohort study looks at the relationship between alcohol consumption and long-term survival, adjusting for smoking habit and physical activity.

METHODS

In 1965, a total of 1536 Italian males aged 45-65 years underwent an examination which included: a general questionnaire, anthropometric measurements, an overall physical examination, ECG recording, blood pressure and serum cholesterol measurements and measurement of food consumption including alcohol. The cohort was followed for total mortality from 1965 to 1995.

RESULTS

During a period of 30 years 1096 deaths occurred. Age-adjusted life expectancy for men assuming a mean daily quantity of 63 g of alcohol (range 4-7 drinks per day) was 21.6 +/- 0.4 years, roughly 2 years more than men taking a mean quantity of 3.7 g (</=1 drink) and men consuming >10 drinks per day. Taking smoking habit into account, the longest survival of 22.4 +/- 0.5 years was observed in non-smokers drinking 4-7 drinks daily; the lowest, 18.5 +/- 0.7 years, in smokers drinking >10 drinks. Stratifying for physical activity, the longest survival (23.4 +/- 0. 7 years) was experienced by men engaged in heavy physical activity at work drinking 1-4 drinks per day.

CONCLUSIONS

The relationship between life expectancy and alcohol consumption (97% wine in this Italian cohort and mostly red wine) is confirmed to be non-linear. Men aged 45-64 at entry drinking about 5 drinks per day have a longer life expectancy than occasional and heavy drinkers.

Fish consumption and coronary heart disease mortality in Finland, Italy, and The Netherlands

Fish consumption seems to protect against death from coronary heart disease (CHD). If this association is due to n-3 polyunsaturated fatty acids, especially fatty fish may be responsible for this protective effect. The association between total, lean, and fatty fish consumption and the risk of CHD mortality was examined in 1,088 Finnish, 1,097 Italian, and 553 Dutch men participants in the Seven Countries Study who were aged 50-69 years and free of CHD around 1970. After 20 years of follow-up, 242 (22.2%) men in Finland, 116 (10.6%) men in Italy, and 105 (19.0%) men in the Netherlands had died of CHD. Cox proportional hazards analysis showed no association between total fish consumption and CHD mortality. After adjustments were made for age, body mass index, smoking, energy intake, and relevant dietary variables, the pooled relative risk for the highest quartile of total fish compared with no fish consumption in the three countries was 1.08 (95% confidence interval: 0.76, 1.53). Lean fish consumption also was not associated with CHD mortality in any country. Fatty fish compared with non-fatty-fish consumption was associated with lower CHD mortality; the adjusted, pooled relative risk for fatty fish consumers was 0.66 (95% confidence interval: 0.49, 0.90). These data suggest that especially fatty fish is protective against CHD mortality.

Comparison of diets of diabetic and non-diabetic elderly men in Finland, The Netherlands and Italy

OBJECTIVE

To evaluate whether dietary recommendations for subjects with diabetes are met among Finnish, Dutch and Italian elderly men with diabetes, and whether the diets of diabetic and non-diabetic men differ in these three countries.

DESIGN

A dietary survey using cross-check dietary history method. A cross-sectional comparison.

SETTING

Thirty-year follow-up of survivors from the Finnish, Dutch and Italian cohorts of the Seven Countries Study.

SUBJECTS

227 elderly men from Finland, 537 from The Netherlands, and 417 from Italy, of whom 8-9% had diabetes.

MAIN RESULTS

The diets of non-diabetic men from the three countries differed markedly from each other. In all three countries diabetic men consumed less added sugar than non-diabetic men. In Italy, in addition, diabetic men consumed more fruits and berries and vegetables. The Dutch diabetic men ate relatively more cereal products, fruits and berries, milk and milk products, cheese, and meat and meat products and drank less alcoholic beverages than non-diabetic men. The diet of both diabetic and non-diabetic Finnish and Dutch men was characterized by high fat content (41% and 40% of energy, respectively). The fat content of the diet was even higher for diabetic than non-diabetic men in Finland and The Netherlands, but not in Italy. The fibre content of the diet was the highest among Dutch men and diabetic men received more dietary fibre than non-diabetic men in The Netherlands and Italy, but not in Finland. The diet of diabetic and non-diabetic Finnish men differed little from each other and was characterized by high nutrient density of several vitamins and minerals. The proportion of protein of energy intake was higher among diabetic than non-diabetic Dutch and Italian men.

CONCLUSIONS

The diet of the diabetic men from Finland, the Netherlands, and Italy resembled more the diet of non-diabetic men from the respective countries than the diet of diabetic men from the other countries. In the diet of Italian diabetic men, the proportions of fat, saturated fatty acids and carbohydrates were nearest the recommended levels.

SPONSORSHIP

The National Institute on Aging, Bethesda, USA, the Dutch Prevention Foundation, the Hague, The Netherlands, the Academy of Finland, and the Sandoz Gerontological Foundation.

Dietary factors and pulmonary function: a cross sectional study in middle aged men from three European countries

BACKGROUND

Results of epidemiological studies relating individual dietary factors to chronic obstructive pulmonary disease (COPD) are inconsistent. To evaluate the cross sectional association of dietary factors with pulmonary function, data were collected from middle aged men in three European countries.

METHODS

The data were collected in the 1960s in Finland (n = 1248), Italy (n = 1386), and the Netherlands (n = 691). Dietary intake was estimated using the cross-check dietary history method. Forced expiratory volume (FEV(0.75) or FEV(1), here called FEV) was measured by spirometry. Associations were adjusted for age, height, smoking, body mass index (BMI), alcohol consumption, and energy intake.

RESULTS

FEV was positively associated with intake of vitamin E in Finland, with intake of fruit in Italy, and with intake of beta-carotene in the Netherlands. In all three countries men with intakes of both fruit and vegetables above the median had a higher FEV than those with a low intake of both foods. The difference in FEV ranged from 110 to 169 ml before and from 53 to 118 ml after energy adjustment. Differences in FEV for intake of three antioxidants (vitamins C and E and beta-carotene) above versus below the median ranged from 61 to 181 ml before and from -35 to 58 ml after energy adjustment. Intake of fish was not associated with FEV.

CONCLUSIONS

In three European countries a high intake of fruit and vegetables was positively associated with pulmonary function. A high intake of all three antioxidants tended to be positively associated with pulmonary function before, but not after, adjustment for energy intake. Associations of individual antioxidants with pulmonary function were not consistent across countries.

Dietary studies on two rural italian population groups of the Seven Countries Study. 3. Trend Of food and nutrient intake from 1960 to 1991

OBJECTIVE

To examine the trend of food and nutrient intake from 1960 to 1991 of the subjects of two rural Italian cohorts of the Seven Countries Study.

DESIGN

Longitudinal study of dietary patterns from 1960 to 1991.

SETTING

Two rural Italian cohorts of Seven Countries Study: Crevalcore in the North near Bologna and Montegiorgio in the Centre near Ancona.

SUBJECTS

Men aged 40-59 y in 1960 examined every 5 or 10 y until 1991.

METHODS

Food intake was assessed by the dietary history method on all available subjects and by the weighed record method in a statistically selected subsample.

RESULTS

A marked decrease of energy intake was observed, due not only to the aging process but also to a remarkable reduction of working activities and life habits. The trend of food group intake as percentage of energy shows an increase for milk, cheese, meat, vegetables, fruit, sweet beverages and cakes, pies and cookies and a decrease for bread and alcoholic beverages, which were more marked in Montegiorgio. The evaluation of the above changes by a Mediterranean Adequacy Index provided the following values: in Crevalcore in 1965 2.9 and in 1991 2.2; in Montegiorgio the corresponding values are 5.6 and 3.9. The Mediterranean Adequacy Index of diet of men from Nicotera (the third rural cohort examined only in 1960), considered the Reference Italian-Mediterranean Diet, is 7.5. Accordingly, in both cohorts dietary habits, different at baseline and rather far from the Reference Italian-Mediterranean type (especially in Crevalcore) became worse with time, particularly in Montegiorgio.

CONCLUSIONS

The changes observed in 31 y in the diet of men from Crevalcore and Montegiorgio suggest the necessity in the longitudinal nutritional epidemiology studies particularly in rapidly changing societies to assess the trend of food intakes and the factors related to it. This is in view of the promotion of nutrition intervention programs.

Consumption of plant foods and stomach cancer mortality in the seven countries study. Is grain consumption a risk factor? Seven Countries Study Research Group

Plant foods are generally considered to be beneficial for health. A higher consumption of fruits, and to a lesser extent vegetables, is consistently associated with a lower risk of stomach cancer. Results on the association between stomach cancer and grain consumption are less clear. We associated plant food consumption with 25-year stomach cancer mortality at population level in the Seven Countries Study. Around 1960, > 12,000 men aged 40-59 years from 7 countries and 16 cohorts were enrolled. In each cohort, dietary information was collected in small random samples. Crude and adjusted associations were calculated for a change of 10% of mean intake. Results differed for the plant foods studied: an inverse association was observed for fruits (adjusted rate ratio = 0.96, 95% confidence interval = 0.91-0.99), a positive relation for refined grains (adjusted rate ratio = 1.07, 95% confidence interval = 1.03-1.12), and no association for total plant foods, vegetables, whole grains, and potatoes. A high intake of refined grains was correlated with a low consumption of fruits. In conclusion, high intake of refined grains may increase stomach cancer risk. However, because adjustment could only be limited in this study, high intake of refined grains may just reflect the deleterious effect of a diet low in fruits or other characteristics associated with low fruit consumption.

Food intake patterns and 25-year mortality from coronary heart disease: cross-cultural correlations in the Seven Countries Study. The Seven Countries Study Research Group

In the Seven Countries Study, associations between the intake of food-groups and 25-year mortality from coronary heart disease (CHD, defined as sudden coronary death or fatal myocardial infarction) were investigated. Baseline surveys were carried out between 1958 and 1964. A number of individual characteristics were measured in 12,763 middle-aged men belonging to 16 cohorts in seven countries (USA, Finland, The Netherlands, Italy, former Yugoslavia, Greece and Japan). Dietary information was collected in sub-samples using the weighed record method. Vital status of all participants was verified at regular intervals during 25 years of follow-up and the underlying cause of death was adjudicated. Eighteen different food-groups and combinations were considered for comparison among cohorts. Large differences in food-group consumption were seen, with high consumption of dairy products in Northern Europe, meat in the USA, vegetables, legumes, fish, and wine in Southern Europe, and cereals, soy products, and fish in Japan. Population death rates from CHD showed large differences, ranging from 268 per 1000 in East Finland to 25 per 1000 in Crete, Greece. Animal food-groups were directly correlated, and vegetable food-groups (except potatoes) as well as fish and alcohol were inversely correlated with CHD mortality. Univariate analysis showed significant positive correlation coefficients for butter (R = 0.887), meat (R = 0.645), pastries (R = 0.752), and milk (R = 0.600) consumption, and significant negative correlation coefficients for legumes (R = -0.822), oils (R = -0.571), and alcohol (R = -0.609) consumption. Combined vegetable foods (excluding alcohol) were inversely correlated (R = -0.519), whereas combined animal foods (excluding fish) were directly correlated (R = 0.798) with CHD death rates. Multivariate stepwise analysis selected butter, lard + margarine and meat as significant predictors and produced an R2 of 0.922. These findings were confirmed by factor analysis. These cross-cultural analyses are consistent with the hypothesis that dietary patterns are important determinants of differences in population CHD death rates, and confirm the opposite effects on apparent risk of animal and vegetable foods.

Dietary fiber and plant foods in relation to colorectal cancer mortality: the Seven Countries Study

Many observational studies have found that higher consumption of vegetables, and to a lesser extent of fruits, was associated with lower risk of colorectal cancer. In particular, fiber or foods high in fiber have received attention in the potential prevention of colorectal cancer. We performed an ecological analysis with data of the Seven Countries Study, to investigate whether intake of fiber and plant foods contributes to cross-cultural differences in 25-year colorectal-cancer mortality in men. In the Seven Countries Study, around 1960 12,763 men aged 40 to 59 were enrolled in 16 cohorts in 7 countries. Baseline dietary information was gathered in small random samples per cohort, and nutrient intakes were based on chemical analyses of the average diets per cohort. Crude and energy-adjusted mortality-rate ratios were calculated for a change of 10% of the mean intake of fiber and plant foods, i.e., total plant foods, fruits, vegetables, potatoes, grains, and related sub-groups. Fiber intake was inversely associated with colorectal-cancer mortality with an energy-adjusted rate ratio of 0.89 (95% confidence interval 0.80-0.97). An increase of 10 gram of daily intake of fiber was associated with a 33% lower 25-year colorectal-cancer mortality risk. Intakes of vitamin B6 [0.84 (0.71-0.99)] and alpha-tocopherol [0.94 (0.89-0.99)] were also inversely associated with risk. Consumption of plant foods and related sub-groups was not related to colorectal cancer. It appears that fiber intake best indicates the part of plant food consumption, including whole grains, that is relevant for lowering colorectal cancer risk.

Dietary fiber and plant foods in relation to colorectal cancer mortality: the Seven Countries Study

Many observational studies have found that higher consumption of vegetables, and to a lesser extent of fruits, was associated with lower risk of colorectal cancer. In particular, fiber or foods high in fiber have received attention in the potential prevention of colorectal cancer. We performed an ecological analysis with data of the Seven Countries Study, to investigate whether intake of fiber and plant foods contributes to cross-cultural differences in 25-year colorectal-cancer mortality in men. In the Seven Countries Study, around 1960 12,763 men aged 40 to 59 were enrolled in 16 cohorts in 7 countries. Baseline dietary information was gathered in small random samples per cohort, and nutrient intakes were based on chemical analyses of the average diets per cohort. Crude and energy-adjusted mortality-rate ratios were calculated for a change of 10% of the mean intake of fiber and plant foods, i.e., total plant foods, fruits, vegetables, potatoes, grains, and related sub-groups. Fiber intake was inversely associated with colorectal-cancer mortality with an energy-adjusted rate ratio of 0.89 (95% confidence interval 0.80-0.97). An increase of 10 gram of daily intake of fiber was associated with a 33% lower 25-year colorectal-cancer mortality risk. Intakes of vitamin B6 [0.84 (0.71-0.99)] and alpha-tocopherol [0.94 (0.89-0.99)] were also inversely associated with risk. Consumption of plant foods and related sub-groups was not related to colorectal cancer. It appears that fiber intake best indicates the part of plant food consumption, including whole grains, that is relevant for lowering colorectal cancer risk.

Dietary patterns and cognitive function in elderly men in Finland, Italy and The Netherlands

OBJECTIVE

To relate dietary patterns to cognitive function in elderly men.

DESIGN

Cross-sectional study.

SETTING

Population based.

SUBJECTS

1049 men aged 70-91 years around 1990 in five cohorts from the Seven Countries Study: Finland (2 cohorts), the Netherlands (1 cohort), and Italy (2 cohorts).

INTERVENTIONS

Food intake was estimated by a cross-check dietary history. Based on the WHO guidelines for the prevention of chronic diseases, a healthy diet indicator was calculated (HDI). A higher HDI indicates a diet more in accordance with the WHO guidelines, and previously we showed that HDI predicted reduced all-cause mortality in our cohorts. Cognitive function was measured using the Mini-Mental State Examination (MMSE), and a score of 23 or lower was used to indicate cognitive impairment.

RESULTS

The prevalence of cognitive impairment varied from 14.4% in Zutphen (The Netherlands) to 42.1% in Crevalcore (Italy). There was a tendency towards a lower prevalence of cognitive impairment associated with increased HDI in four out of five cohorts (not in East Finland). In Zutphen this association was borderline significant (OR=0.81; 95% CI 0.63-1.04) after adjustment for age, education, cigarette smoking, alcohol consumption and energy intake. In Crevalcore the association was statistically significant (OR = 0.75; 95% CI 0.58-0.97).

CONCLUSIONS

A healthy diet might be associated with a better cognitive function in elderly men. However, since the results were not consistent over all five cohorts, further research is needed to confirm this finding and to decide whether this association is causal.

Vitamin intake and status in a group of subjects from the Gubbio area Italy

beta-Carotene, retinol, niacin, riboflavin, thiamin intake and blood nutritional status beta-carotene, retinol, and alpha-tocopherol) were investigated in a group of 79 subjects (35 males and 44 females) of 30 years and over, living in three rural hamlets in the Gubbio area (Central Italy) to see if there were any differences in nutrient intake using different methods of dietary assessment and if there was a relationship between vitamin intake and status. Vitamin intakes were assessed by three different methods: dietary history, two-day weighed record and two-day duplicate-portion chemical analysis. Vitamin content of duplicate diets was assessed by semiautomated HPLC methods. Plasma vitamin status was assessed by semi-automated isocratic straight-phase HPLC methods. The three methods of dietary assessment were compared using the Student's paired t-test and Wilcoxon-Mann-Whitney test. Between the two days weighed record and diet history, significant differences were observed for beta-carotene and thiamin. Between the two-day weighed record and chemical analysis, significantly differences were found for beta-carotene, riboflavin and thiamin. Between diet history and chemical analysis, significant differences were obtained for beta-carotene, riboflavin and thiamin. The t-test analysis showed different results according to sex and age. Plasma vitamin status using the current cut-off criteria showed some deficiencies for beta-carotene. As on other occasions no correlation was observed between data from diet history, weighed record and chemical analysis of duplicate portions and the corresponding blood vitamin levels for the whole group of subjects.

Dietary pattern and 20 year mortality in elderly men in Finland, Italy, and The Netherlands: longitudinal cohort study

OBJECTIVE

To investigate the association of dietary pattern and mortality in international data.

DESIGN

Cohort study with 20 years' follow up of mortality.

SETTING

Five cohorts in Finland, the Netherlands, and Italy.

SUBJECTS

Population based random sample of 3045 men aged 50-70 years in 1970.

MAIN OUTCOME MEASURES

Food intake was estimated using a cross check dietary history. In this dietary survey method, the usual food consumption pattern in the 6-12 months is estimated. A healthy diet indicator was calculated for the dietary pattern, using the World Health Organisation's guidelines for the prevention of chronic diseases. Vital status was verified after 20 years of follow up, and death rates were calculated.

RESULTS

Dietary intake varied greatly in 1970 between the three countries. In Finland and the Netherlands the intake of saturated fatty acids and cholesterol was high and the intake of alcohol was low; in Italy the opposite was observed. In total 1796 men (59%) died during 20 years of follow up. The healthy diet indicator was inversely associated with mortality (P for trend < 0.05). After adjustment for age, smoking, and alcohol consumption, the relative risk in the group with the healthiest diet indicator compared with the group with the least healthy was 0.87 (95% confidence interval 0.77 to 0.98). Estimated relative risks were essentially similar within each country.

CONCLUSIONS

Dietary intake of men aged 50-70 is associated with a 20 year, all cause mortality in different cultures. The healthy diet indicator is useful in evaluating the relation of mortality to dietary patterns.

The inverse relation of average population blood pressure and stroke mortality rates in the seven countries study: a paradox

This study attempts to explain the unexpected finding of an inverse population (ecological) relationship between mean systolic blood pressure levels and stroke death rates in 25 years follow-up of the Seven Countries Study, a cross-cultural study of cardiovascular disease. Sixteen cohorts of all men aged 40-59 in seven countries (one cohort in the USA, two in Finland, one in the Netherlands, three in Italy, two in Croatia (former Yugoslavia), three in Serbia (former Yugoslavia), two in Greece, two in Japan) were surveyed from 1958 to 1964. Risk factors and personal characteristics were measured and follow-up for vital status and cause of death was then carried out over 25 years. Analyses were based on comparisons of mean levels of risk factors and death rates within and among the 16 cohorts. Mean entry population levels of systolic blood pressure among the cohorts were strongly and inversely related with their 25-year stroke death rates (R -0.55; CI -0.81 and -0.06; p = 0.0276). Within cohorts in contrast, the individual relation of blood pressure and stroke was strongly positive and significant in 14 of the 16 cohorts. Mean population levels of serum cholesterol were inversely and strongly related to stroke death rates (R -0.79; CI -0.92 and -0.46; p = 0.0003), while the partial correlation coefficient of systolic blood pressure, computed in models including serum cholesterol, became small and not significant (-0.05; CI -0.55 and +0.48; p = 0.8537). Age at death for stroke (average 68.9 +/- 7.1 years) was significantly higher than age at dath from myocardial infarction and sudden death (average 65.8 +/- 7.8 years) suggesting a competition effect between the conditions. Multivariate models including population average systolic blood pressure and serum cholesterol provided no added explanation for the lack of direct and significant relationship of population blood pressure with stroke death rates. They were based on these variables: age at stroke death, age at myocardial infarction death or and sudden death, death rates from myocardial infarction and sudden death, the interaction term of systolic blood pressure with serum cholesterol and the multivariate coefficients for systolic blood pressure from Cox models run in individuals. Similar findings were obtained using diastolic instead of systolic blood pressure and excluding the Japanese cohorts. The paradox of the inverse ecologic relation of population blood pressure and stroke mortality and a direct relation for individual is only partly explained by the cofounding effect of population mean serum cholesterol levels. An effect of low cholesterol levels on excess stroke mortality cannot be excluded. A major limitation of the study was our inability to segregate thrombotic from heamorrhagic strokes.

Changes in population cholesterol levels and coronary heart disease deaths in seven countries

BACKGROUND

Are trends in coronary heart disease deaths based on risk factor changes?

OBJECTIVE

To study the relationship between trends in coronary deaths and changes in blood cholesterol in the Seven Countries Study.

MATERIAL AND METHODS

Sixteen cohorts of men aged 40-59 years from seven countries (U.S.A., Finland, the Netherlands, Italy, Croatia (former Yugoslavia), Serbia (former Yugoslavia), Greece, Japan) were units for the analyses of serum cholesterol measured at entry and after 5 and 10 years, and for mortality over 25 years.

RESULTS

In the populations, the ecological relationship of mean serum cholesterol at entry to late coronary heart disease death rates during the 10- to 25-year follow-up was weak, with an R-square of 0.31. Cholesterol measurements made at year 10, and an indicator of cholesterol change during the first 10 years, increased the association (R-square, 0.49). A negative and significant interaction was shown between baseline population cholesterol levels and their 10-year change. As an indicator of acceleration in mortality, cholesterol change over 10 years was also positively correlated (partial R-square 0.44) with the ratio of 25-year to 5-year deaths.

CONCLUSIONS

In the Seven Countries Study, late coronary heart disease death rates are largely "explained' by changes in blood cholesterol levels during the early phases of the study, mainly due to increases in lower cholesterol levels among some cohorts.

Haemostatic parameters and lifestyle factors in elderly men in Italy and The Netherlands

The association between plasma fibrinogen, factor VII, factor X, activated partial thromboplastin time, antithrombin III and the lifestyle factors cigarette smoking, alcohol use, fat intake and physical activity was assessed in 802 men aged 70-90 years in Zutphen (The Netherlands), Montegiorgio and Crevalcore (Italy). Smoking was positively associated with fibrinogen, also after adjustment for other lifestyle factors, age, use of anticoagulants and aspirin like drugs, body mass index, and history of myocardial infarction. Alcohol use was associated with increased levels of factor X and decreased levels of antithrombin III. Fat intake was positively associated with antithrombin III. Between cohorts, considerable differences were observed in levels of haemostatic parameters and the lifestyle factors. Compared to the mediterranean cohorts the Zutphen cohort showed the highest levels of fibrinogen and factor VII. Differences in lifestyle factors could, however, not explain differences between cohorts in levels of any of the haemostatic parameters, despite the observed associations between lifestyle factors and haemostatic parameters.

Changes in body weight in relation to mortality in 6441 European middle-aged men: the Seven Countries Study

OBJECTIVES

To study the relation between changes in body weight and subsequent mortality.

DESIGN

Prospective follow-up study.

SETTING

Population study.

SUBJECTS

6441 men aged 40-59 y at baseline participating in the European cohorts of the Seven Countries Study. The men were divided into groups depending on their weight pattern ascertained from three weight measurements with intervals of 5 years. They were also divided in quartiles according to the degree of weight variability.

MAIN OUTCOME MEASURES

All-cause and cause-specific mortality during 15 years following the last weight measurement. Deaths occurring during the first 5 years of follow-up were excluded.

RESULTS

Significantly elevated hazard ratios (RR) for death from all causes (RR = 1.3; 95% confidence interval (CI): 1.2-1.5), all cardiovascular diseases (RR = 1.2; 95% CI: 1.0-1.5) and other causes (RR = 1.6; 95% CI: 1.2-2.2) were found for men with a decreasing weight compared with men with a constant weight. A fluctuating weight was associated with an increased risk of all cause mortality (RR = 1.2; 95% CI: 1.0-1.4), coronary heart disease (RR = 1.5; 95% CI: 1.0-1.9) and myocardial infarction (RR = 1.5; 95% CI: 1.0-2.2). The group of men with an increasing body weight also had elevated hazard ratios for dying from coronary heart disease and myocardial infarction, but these were only significant when the total 15-year follow-up was analyzed. The risks of dying from all-causes, cardiovascular disease, cancer and other causes were increased in the upper quartile versus the lower quartile of weight variability.

CONCLUSIONS

The results of the present study show that a decreasing and a fluctuating body weight are associated with increased mortality. An average increase of 7 kg body weight was associated with an elevated risk of dying from coronary heart disease and myocardial infarction. Lowest mortality in these middle-aged men was found in those who maintained a constant body weight.

Dietary intake in five ageing cohorts of men in Finland, Italy and The Netherlands

OBJECTIVE

To obtain insight into dietary habits of elderly people and how these habits have evolved from middle to old age.

DESIGN

Cross-sectional study of dietary patterns around 1990; retrospective cohort study of changes in dietary intake since middle age.

SETTING

Five cohorts: East and West Finland, Zutphen (Netherlands), Crevalcore (Italy), and Montegiorgo (Italy).

SUBJECTS

Men aged 70-90 years around 1990.

METHODS

Food intake was estimated using a cross-check dietary history adjusted to the local situation.

RESULTS

(i) Cross-sectional: Significant differences were observed between the countries for all food groups, energy and nutrients (P < 0.05). The Finnish diet was characterised by a high consumption of animal products and potatoes, the Italian diet by a high consumption of cereals, vegetables, fruits and alcohol. The Dutch diet was generally intermediate. (ii) Longitudinal: The decrease in energy intake since middle age varied from 4.2 MJ/day in the Finnish cohorts to 2.1 MJ/day in Italy. Also the consumption of most food groups decreased but the consumption of vegetables and fruits increased. Saturated fatty acid intake decreased by 3 E% in the Finnish cohorts and decreased by < 1 E% in Italy. Alcohol intake decreased by approximately 7 E% in Italy while it increased by 2.5 E% in the Netherlands.

CONCLUSIONS

Although the general patterns of dietary intake of the different cultures still can be recognised at old age, the variation between them has become smaller. Compared to their dietary intake at middle age, however, the dietary pattern of the Finnish and Dutch cohorts has changed slightly in the direction of a healthy diet, while the diet of the Italian men remained Mediterranean, and thus more healthy, at old age.

Biochemical validation of a self-administered semi-quantitative food-frequency questionnaire

The present study is a biochemical validation of a food-frequency questionnaire (FFQ) with optical reading, i.e. containing food portion photographs to help to assess quantities. Forty-four healthy subjects, non-smokers and not taking vitamin supplements, were recruited for the study. After completion of the questionnaire, subjects were asked to keep a 7 d weighed dietary record (7DR). Three 24 h urine samples were collected on 3 different days over the week of food recording for the analysis of urea-N, P and K. On the 4th day of food recording, blood was collected for determination of alpha-tocopherol, beta-carotene and ascorbic acid. N, P and K determined in urines and from 7DR were significantly correlated (Spearman rank correlation test), r values being 0.77, 0.57 and 0.42 respectively. The correlations with the FFQ were significant only for N (r 0.45) and P (r 0.39). Blood ascorbic acid and beta-carotene concentrations correlated with dietary intake when determined from 7DR (both r 0.44), but not when determined from FFQ. No correlation was found for alpha-tocopherol. The data obtained seem to prove the validity of the FFQ in defining eating patterns in terms of some nutrients, but not vitamins, at least as far as non-supplemented subjects are concerned. The way in which foods were grouped in the questionnaire could account for these results.

Serum total cholesterol and long-term coronary heart disease mortality in different cultures. Twenty-five-year follow-up of the seven countries study

OBJECTIVE

To compare the relationship between serum total cholesterol and long-term mortality from coronary heart disease (CHD) in different cultures.

DESIGN

Total cholesterol was measured at baseline (1958 through 1964) and at 5- and 10-year follow-up in 12,467 men aged 40 through 59 years in 16 cohorts located in seven countries: five European countries, the United States, and Japan. To increase statistical power six cohorts were formed, based on similarities in culture and cholesterol changes during the first 10 years of follow-up.

MAIN OUTCOME MEASURES

Relative risks (RRs), estimated with Cox proportional hazards (survival) analysis, for 25-year CHD mortality for cholesterol quartiles and per 0.50-mmol/L (20-mg/dL) cholesterol increase. Adjustment was made for age, smoking, and systolic blood pressure.

RESULTS

The age-standardized CHD mortality rates in the six cohorts ranged from 3% to 20%. The RRs for the highest compared with the lowest cholesterol quartile ranged from 1.5 to 2.3, except for Japan's RR of 1.1. For a cholesterol level of around 5.45 mmol/L (210 mg/dL), CHD mortality rates varied from 4% to 5% in Japan and Mediterranean Southern Europe to about 15% in Northern Europe. However, the relative increase in CHD mortality due to a given cholesterol increase was similar in all cultures except Japan. Using a linear approximation, a 0.50-mmol/L (20-mg/dL) increase in total cholesterol corresponded to an increase in CHD mortality risk of 12%, which became an increase in mortality risk of 17% when adjusted for regression dilution bias.

CONCLUSION

Across cultures, cholesterol is linearly related to CHD mortality, and the relative increase in CHD mortality rates with a given cholesterol increase is the same. The large difference in absolute CHD mortality rates at a given cholesterol level, however, indicates that other factors, such as diet, that are typical for cultures with a low CHD risk are also important with respect to primary prevention.

Relationship between eating patterns meeting recommendations and subsequent mortality in 20 years

OBJECTIVE

Study of the relationships of conformity to dietary recommendations and subsequent rates of total mortality and mortality from specific causes.

DESIGN

Prospective investigation of risk factors related to cardiovascular disease.

SETTING

Two Italian rural cohorts of the Seven Countries Study.

SUBJECTS

The study populations are defined samples from two villages, Crevalcore in Northern Italy and Montegiorgio in Central Italy. The examination in 1965, which included an individual dietary survey, involved 1538 men aged 45-64 years. The 20-year follow-up system was able to track every participant.

RESULTS

Conformity to recommended levels of intake of carbohydrates (55-75% of calories) is associated to the relative risks: 0.84 (0.68-1.03) for total mortality, 0.73 (0.50-1.07) for cancer mortality, 1.34 (0.90-1.99) for coronary heart disease mortality. Relative risks for other nutrients are reported.

CONCLUSIONS

Overall, recommended levels of intake of macronutrients are associated with lower total mortality, but are not equally appropriate for specific causes of death, cancer and coronary heart disease. Diet-associated differences in mortality persisted after adjustment for confounding by age, smoking habit and physical activity. In this population, intakes meeting the principal recommendations (total carbohydrate and total fat) seem to involve automatically meeting the other recommendations.

SPONSORSHIP

Research partly supported by the project 'ACRO-clinical uses of Oncological Research' (contract 93.02289.PF39) and by the project 'FATMA-Risk Factors and Disease Control' (contract 93.00773.PF41) of the Italian National Research Council, CNR.