Associations between concentrations of α- and γ-tocopherol and concentrations of glucose, glycosylated haemoglobin, insulin and C-peptide among US adults

Our objective was to study the cross-sectional associations between concentrations of α- and γ-tocopherol and concentrations of glucose, glycosylated haemoglobin, insulin and C-peptide among US adults. We used data for 1289 participants without self-reported diabetes who were aged ≥20 years in the National Health and Nutrition Examination Survey 1999–2000. α-Tocopherol concentration was inversely associated with glucose concentration (β per mmol/l=−0·01064, se 0·00356, P=0·004) after adjusting for age, sex, race or ethnicity, education, smoking status, concentrations of total cholesterol and triacylglycerols, systolic blood pressure, waist circumference, alcohol use, physical activity, time watching television or videos or using a computer, and use of vitamin/mineral/dietary supplements. Among 659 participants who did not report using supplements, this association was no longer significant whereas the concentration of α-tocopherol was inversely associated with concentration of C-peptide (β per mmol/l=−0·01121, se 0·00497, P=0·024). γ-Tocopherol concentration was positively associated with concentration of glucose (β per mmol/l=0·09169, se 0·02711, P=0·001) and glycosylated haemoglobin (β per mmol/l=0·04954, se 0·01284, P<0·001), but not insulin or C-peptide. The relationships between physiologic concentrations of the various forms of vitamin E and measures of glucose intolerance deserve additional investigation.

A prospective evaluation of the angiotensin-converting enzyme D/I polymorphism and left ventricular remodeling in the 'Healing and Early Afterload Reducing Therapy' study

The D/I (deletion, D, insertion, I) polymorphism of the angiotensin-converting enzyme (ACE) gene has been extensively studied for its association with a number of cardiovascular and other disease states. However, its potential association with differential clinical efficacy of ACE inhibitors (ACE-I) administered to patients who had suffered a myocardial infarction (MI), i.e. the prevention of left ventricular (LV) remodeling, has so far not been specifically studied. The aim of the study was to investigate whether the D/I polymorphism of the ACE gene is associated with the incidence of post-MI LV remodeling in patients drawn from the 'Healing and Early Afterload Reducing Therapy' (HEART) Study. The ACE D/I polymorphism was characterized by the polymerase chain reaction (PCR) in 265 subjects from the 'Healing and Early Afterload Reducing Therapy' Study, a double-blind, placebo-controlled trial with the objective of determining whether early or delayed administration of the ACE-I, ramipril, in patients with acute anterior wall MI would be optimal in reducing LV enlargement. Selected frequencies for the ACE D and I alleles were 0.59 and 0.41 (placebo-high dose group), 0.56 and 0.44 (low dose-low dose group), and, 0.60 and 0.40 (high dose-high dose group), respectively. All observed genotype frequencies were in Hardy-Weinberg equilibrium. There was no evidence for an association between genotype and outcome regarding LV size or function, nor with the initial blood pressure response after ACE-I administration (adjusted for covariates). Our data provide no evidence for an association of the ACE D/I polymorphism with the risk of LV remodeling post-MI in the presence of ACE-I therapy, and therefore do not suggest that differential clinical efficacy of ACE-inhibitors is related to this genetic marker.

Age-related maculopathy in a randomized trial of low-dose aspirin among US physicians

OBJECTIVE

To examine the development of age-related maculopathy (ARM) in a large-scale trial of low-dose aspirin treatment.

METHODS

The Physicians' Health Study I was a randomized, double-masked, placebo-controlled trial of low-dose aspirin (325 mg every other day) and beta carotene (50 mg every other day) in the prevention of cardiovascular disease and cancer conducted among 22 071 US male physicians aged 40 to 84 years in 1982. A total of 21 216 participants did not report ARM at baseline, were followed up for at least 7 years, and are included in this analysis.

MAIN OUTCOME MEASURES

Total ARM, defined as a self-report confirmed by medical record evidence of an initial diagnosis subsequent to randomization, and ARM with vision loss, defined as total ARM but with vision loss to 20/30 or worse attributable to ARM.

RESULTS

Early termination of the randomized aspirin component of the Physicians' Health Study I, after an average of 60.2 months of treatment and follow-up due to a statistically extreme 44% reduced risk of first myocardial infarction, resulted in a far lower number of incident cases of ARM during the aspirin treatment period than would have accrued without early termination. Thus, during an average of 60.2 months of follow-up, a total of 117 cases of ARM were confirmed, including 57 cases responsible for vision loss to 20/30 or worse. There were 51 cases of ARM in the aspirin group and 66 in the placebo group (relative risk, 0.77; 95% confidence interval, 0.54-1.11). For ARM with vision loss, there were 25 cases in the aspirin group and 32 in the placebo group (relative risk, 0.78; 95% confidence interval, 0.46-1.32).

CONCLUSIONS

These randomized trial data tend to exclude any large beneficial effect of 5 years of low-dose aspirin treatment on ARM. However, a smaller, but potentially important, beneficial effect cannot be ruled out and would require testing in randomized trials of adequate size and duration.

Aspirin use and risk of cataract in posttrial follow-up of Physicians' Health Study I

BACKGROUND

In Physicians' Health Study I, randomized trial results indicated no major beneficial effect of 5 years of low-dose aspirin treatment on total cataract (relative risk [RR], 0.94; 95% confidence interval [CI], 0.79-1.13) or cataract extraction (RR, 0.81; 95% CI, 0.65-1.01) during the period of treatment.

OBJECTIVE

To examine the effect of assigned aspirin treatment and posttrial, self-selected aspirin use on the risk of age-related cataract over the 15 years of follow-up of Physicians' Health Study I.

METHODS

Participants were 20 968 US male physicians enrolled in Physicians' Health Study I who did not report cataract at baseline. At 7 years, after termination of the randomized aspirin component of the trial, self-selected aspirin use was computed from annual questionnaires. The main outcome measures were age-related cataract and extraction of age-related cataract, defined as an incident, age-related lens opacity responsible for a reduction in best-corrected visual acuity to 20/30 or worse based on self-report confirmed by medical record review.

RESULTS

During a median of 14.9 years of follow-up, there were 2081 cataracts and 1198 cataract extractions. Overall, the age- and beta carotene-adjusted RR of cataract in men assigned to aspirin compared with those assigned to placebo was 1.09 (95% CI, 1.00-1.18). For cataract extraction, the RR was 1.09 (95% CI, 0.98-1.22). During a median posttrial follow-up of 7.9 years, a total of 1225 incident cataracts and 635 cataract extractions were documented. The multivariate RR of cataract in men who reported using aspirin frequently (>/=180 days per year) at 7 years compared with nonusers (0-13 days per year) was 1.20 (95% CI, 1.03-1.40). For cataract extraction, the multivariate RR was 1.22 (95% CI, 0.98-1.51). Results for diagnosis and extraction of cataract subtypes were similar.

CONCLUSIONS

Analyses based on randomized aspirin assignment indicated no long-term benefit of 5 years of low-dose aspirin treatment on total cataract or cataract extraction. Posttrial, observational data also indicated no decreased risk of cataract in aspirin users and suggested a small increased risk of cataract in aspirin users. Further randomized trial data to investigate the effect of longer term treatment with low-dose aspirin are being collected as part of the ongoing Women's Health Study, a randomized trial of low-dose aspirin and vitamin E among 39 876 apparently healthy, postmenopausal US female health professionals.

Periodontal disease and risk of subsequent cardiovascular disease in U.S. male physicians

OBJECTIVES

We sought to prospectively assess whether self-reported periodontal disease is associated with subsequent risk of cardiovascular disease in a large population of male physicians.

BACKGROUND

Periodontal disease, the result of a complex interplay of bacterial infection and chronic inflammation, has been suggested to be a predictor of cardiovascular disease.

METHODS

Physicians' Health Study I was a randomized, double-blind, placebo-controlled trial of aspirin and beta-carotene in 22,071 U.S. male physicians. A total of 22,037 physicians provided self-reports of presence or absence of periodontal disease at study entry and were included in this analysis.

RESULTS

A total of 2,653 physicians reported a personal history of periodontal disease at baseline. During an average of 12.3 years of follow-up, there were 797 nonfatal myocardial infarctions, 631 nonfatal strokes and 614 cardiovascular deaths. Thus, for each end point, the study had >90% power to detect a clinically important increased risk of 50%. In Cox proportional hazards regression analysis adjusted for age and treatment assignment, physicians who reported periodontal disease at baseline had slightly elevated, but statistically nonsignificant, relative risks (RR) of nonfatal myocardial infarction, (RR, 1.12; 95% confidence interval [CI], 0.92 to 1.36), nonfatal stroke (RR, 1.10; CI, 0.88 to 1.37) and cardiovascular death (RR, 1.20; CI, 0.97 to 1.49). Relative risk for a combined end point of all important cardiovascular events (first occurrence of nonfatal myocardial infarction, nonfatal stroke or cardiovascular death) was 1.13 (CI, 0.99 to 1.28). After adjustment for other cardiovascular risk factors, RRs were all attenuated and nonsignificant.

CONCLUSIONS

These prospective data suggest that self-reported periodontal disease is not an independent predictor of subsequent cardiovascular disease in middle-aged to elderly men.

A prospective study of blood pressure and risk of cataract in men

PURPOSE

Cataract is the leading cause of blindness worldwide. Blood pressure has been identified as a risk factor in some, but not all, previous studies. We aimed to test prospectively the hypothesis that high blood pressure increases risk of age-related cataract.

METHODS

Participants in the Physicians' Health Study of 22,071 men aged 40 to 84 years in 1982 completed annual questionnaires that provided medical history including self-reported blood pressure, treatment for hypertension, and cataract. Over 12 years, 1392 cataracts were confirmed by medical record review among 17,762 physicians with complete data and no reported cataract at baseline. We used proportional hazards regression models to examine relations of systolic blood pressure (SBP), diastolic blood pressure (DBP), hypertension, as well as antihypertensive medications with cataract, after control for potential confounding factors.

RESULTS

In models adjusting for age and randomized treatment assignment, there was a significant relationship of SBP, but not DBP, hypertension, or antihypertensive medications (each p > or = 0.23) with incident cataract. Estimates were attenuated after adjusting for multiple potential confounders, although the relationship of SBP with incident cataract remained significant. The multivariate adjusted rate ratio (95% confidence interval) of cataract for SBP > or = 150 versus < 120 mm Hg was 1.31 (1.04-1.66), p for trend = 0.04. For DBP > or = 90 versus < 70 mm Hg, the estimate was 1.11 (0.84-1.45), p for trend = 0.33.

CONCLUSIONS

Overall, these data suggest that the relationship of blood pressure with cataract is not strong, and is subject to confounding by other risk factors. The modest magnitude of the association with SBP and lack of significant relationships with DBP and hypertension may suggest a non-causal relationship of blood pressure with cataract.

Diabetes and all-cause and coronary heart disease mortality among US male physicians

BACKGROUND

While diabetes has long been associated with increased risk of coronary heart disease (CHD), the magnitude of risk of diabetes-related CHD is uncertain.

OBJECTIVE

To evaluate the impact of diabetes and prior CHD on all-cause and CHD mortality.

METHODS

In a prospective cohort study of 91 285 US male physicians aged 40 to 84 years, participants were divided into 4 groups: (1) a reference group of 82 247 men free of both diabetes and CHD (previous myocardial infarction and/or angina) at baseline, (2) 2317 men with a history of diabetes but not CHD, (3) 5906 men with a history of CHD but not diabetes, and (4) 815 men with a history of both diabetes and CHD. Rates of all-cause and CHD mortality were compared in these groups.

RESULTS

Over 5 years (49 7952 person-years of follow-up), 3627 deaths from all causes were documented, including 1242 deaths from CHD. Compared with men with no diabetes or CHD, the age-adjusted relative risk of death from any cause was 2.3 (95% confidence interval [CI], 2.0-2.6) among men with diabetes and without CHD, 2.2 (95% CI, 2.0-2.4) among men with CHD and without diabetes, and 4.7 (95% CI, 4.0-5.4) among men with both diabetes and CHD. The relative risk of CHD death was 3.3 (95% CI, 2.6-4.1) among men with diabetes and without CHD, 5.6 (95% CI, 4.9-6.3) among men with CHD and without diabetes, and 12.0 (95% CI, 9.9-14.6) among men with both diabetes and CHD. Multivariate adjustment for body mass index, smoking status, alcohol intake, and physical activity as well as stratification by these variables did not materially alter these associations.

CONCLUSIONS

These prospective data indicate that diabetes is associated with a substantial increase in all-cause and CHD mortality. For all-cause mortality, the magnitude of excess risk conferred by diabetes is similar to that conferred by a history of CHD; for mortality from CHD, a history of CHD is a more potent predictor of death. The presence of both diabetes and CHD, however, identifies a particularly high-risk group.

A prospective study of cigarette smoking and the incidence of diabetes mellitus among US male physicians

PURPOSE

To determine the association between cigarette smoking and the incidence of type 2 diabetes mellitus.

SUBJECTS AND METHODS

We studied 21,068 US male physicians aged 40 to 84 years in the Physicians' Health Study who were initially free of diagnosed diabetes mellitus, cardiovascular disease, and cancer. Information about cigarette smoking and other risk indicators was obtained at baseline. The primary outcome was reported diagnosis of type 2 diabetes mellitus.

RESULTS

During 255,830 person-years of follow-up, 770 new cases of type 2 diabetes mellitus were identified. Smokers had a dose-dependent increased risk of developing type 2 diabetes mellitus: compared with never smokers, the age-adjusted relative risk was 2.1 (95% confidence interval [CI]: 1.7 to 2.6) for current smokers of > or = 20 cigarettes per day, 1.4 (95% CI: 1.0 to 2.0) for current smokers of <20 cigarettes per day, and 1.2 (95% CI: 1.0 to 1.4) for past smokers. After multivariate adjustment for body mass index, physical activity, and other risk factors, the relative risks were 1.7 (95% CI: 1.3 to 2.3) for current smokers of > or = 20 cigarettes per day, 1.5 (95% CI: 1.0 to 2.2) for current smokers of <20 cigarettes per day, and 1.1 (95% CI: 1.0 to 1.4) for past smokers. Total pack-years of cigarette smoking was also associated with the risk of type 2 diabetes mellitus (P for trend <0.001).

CONCLUSIONS

These prospective data support the hypothesis that cigarette smoking is an independent and modifiable determinant of type 2 diabetes mellitus.

Smoking cessation and risk of age-related cataract in men

CONTEXT

Although cigarette smoking has been shown to be a risk factor for age-related cataract, data are inconclusive on the risk of cataract in individuals who quit smoking.

OBJECTIVE

To examine the association between smoking cessation and incidence of age-related cataract.

DESIGN

Prospective cohort study conducted from 1982 through 1997, with an average follow-up of 13.6 years.

SETTING AND PARTICIPANTS

A total of 20,907 US male physicians participating in the Physicians' Health Study I who did not have a diagnosis of age-related cataract at baseline and had reported their level of smoking at baseline.

MAIN OUTCOME MEASURES

Incident age-related cataract defined as self-report confirmed by medical record review, diagnosed after study randomization and responsible for vision loss to 20/30 or worse, and surgical extraction of incident age-related cataract, in relation to smoking status and years since quitting smoking.

RESULTS

At baseline, 11% were current smokers, 39% were past smokers, and 50% were never smokers. Average reported cumulative dose of smoking at baseline was approximately 2-fold greater in current than in past smokers (35.8 vs 20.5 pack-years). Two thousand seventy-four incident cases of age-related cataract and 1193 cataract extractions were confirmed during follow-up. Compared with current smokers, multivariate relative risks (RRs) of cataract in past smokers who quit smoking fewer than 10 years, 10 to fewer than 20 years, and 20 or more years before the study were 0.79 (95% confidence interval [CI], 0.64-0.98), 0.73 (95% CI, 0.61-0.88), and 0.74 (95% CI, 0.63-0.87), respectively, after adjustment for other risk factors for cataract and age at smoking inception. The RR for never smokers was 0.64 (95% CI, 0.54-0.76). The reduced risk in past smokers was principally due to a lower total cumulative dose (RR of cataract for increase of 10 pack-years of smoking, 1.07; 95% CI, 1.04-1.10). A benefit of stopping smoking independent of cumulative dose was suggested in some analyses. Results for cataract extraction were similar.

CONCLUSION

These prospective data indicate that while some smoking-related damage to the lens may be reversible, smoking cessation reduces the risk of cataract primarily by limiting total dose-related damage to the lens. JAMA. 2000;284:713-716

Alcohol consumption and risk of coronary heart disease by diabetes status

BACKGROUND

An inverse association between moderate alcohol consumption and coronary heart disease (CHD) has been observed in several epidemiological studies. To assess whether a similar association exists among diabetics, we examined the relation between light to moderate alcohol consumption and CHD in men with and without diabetes mellitus in a prospective cohort study.

METHODS AND RESULTS

A total of 87 938 US physicians (2790 with diagnosed diabetes mellitus) who were invited to participate in the Physicians' Health Study and were free of myocardial infarction, stroke, cancer, or liver disease at baseline were followed for an average of 5.5 years for death with CHD as the underlying cause. During 480 876 person-years of follow-up, 850 deaths caused by CHD were documented: 717 deaths among nondiabetic men and 133 deaths among diabetic men. Among men without diabetes at baseline, the relative risk estimates for those reporting rarely/never, monthly, weekly, and daily alcohol consumption were 1.00 (referent), 1.02, 0. 82, and 0.61 (95% CI 0.49 to 0.78; P for trend <0.0001) after adjustment for age, aspirin use, smoking, physical activity, body mass index, and history of angina, hypertension, and high cholesterol. Among men with diabetes at baseline, the relative risk estimates were 1.00 (referent), 1.11, 0.67, and 0.42 (95% CI 0.23 to 0.77; P for trend=0.0019).

CONCLUSIONS

These results suggest that light to moderate alcohol consumption is associated with similar risk reductions in CHD among diabetic and nondiabetic men.

Cigarette smoking and risk of prostate cancer in the physicians' health study (United States)

To assess whether cigarette smoking is associated with prostate cancer incidence or mortality, we analyzed a large cohort of 22,071 men, aged 40-84 at baseline, in the Physicians' Health Study. During an average of 12.5 years of follow-up, we documented 996 cases of prostate cancer, including 113 fatal cases. Men were categorized according to smoking status, total pack-years smoked, and duration of smoking. We used Cox proportional hazard models to estimate the relative risks associated with smoking. Compared to never smokers, the age-adjusted relative risks (RR) of total prostate cancer were 1. 14 (95% confidence interval [CI] = 1.00-1.30) for past smokers, 1.10 (95% CI = 0.78-1.55) for current smokers of less than 20 cigarettes per day, and 1.10 (95% CI = 0.84-1.44) for current smokers of 20 or more cigarettes per day. Adjustment for body mass index, height, alcohol intake, and physical activity did not materially alter these findings. No significant association was observed in analyses of total pack-years smoked or duration of smoking. The results were similar for non-fatal and fatal prostate cancer. These data indicate no material association between cigarette smoking and prostate cancer incidence or mortality.

Baseline self-reported cataract and subsequent mortality in Physicians' Health Study I

PURPOSE

To examine whether a reported history of cataract, a possible marker of aging, is associated with future mortality.

METHODS

Participants were 18,669 of the 22,071 U.S. male physicians enrolled in the Physicians' Health Study I who had complete information at study entry, including self-report of presence or absence of baseline cataract. Participants were without a previous history of myocardial infarction, stroke, transient cerebral ischemia, or cancer (except non-melanoma skin cancer). Reported deaths were confirmed by an End Points Committee of physicians.

RESULTS

A total of 581 participants reported a personal history of cataract at baseline. During an average of 12.4 years of follow-up, there were 1,514 deaths including 496 due to cardiovascular (CV) and 1,018 due to non-CV causes. After adjustment for differences in age, men who reported cataract at baseline had a non-significant 9% increased risk of death from any cause compared to men who did not report cataract (RR, 1.09; 95% CI, 0.91-1.30). The RRs were 1.03 (95% CI, 0.75-1.41) for CV death and 1.12 (95% CI, 0.90-1.40) for non-CV death. Adjustment for other risk factors had little effect on these estimates. Similar results were obtained in analyses conducted separately among those with and without self-reported diabetes at baseline.

CONCLUSIONS

These results from a population of generally healthy physicians indicate that a report of a history of cataract is not associated with any material increase in mortality after adjustment for differences in age between men with and without cataract. Additional investigation of this cohort is in progress to determine whether incident age-related cataracts as well as their subtypes, confirmed by medical record review, are associated with increased mortality.

Alcohol consumption and risk of type 2 diabetes mellitus among US male physicians

OBJECTIVE

To examine the association between low to moderate alcohol consumption and the incidence of type 2 diabetes mellitus (DM) in men.

DESIGN

Prospective cohort study.

SUBJECTS AND METHODS

Over an average period of 12.1 years, we evaluated 20 951 participants in the Physicians' Health Study between ages 40 and 84 years who were free of cardiovascular disease, cancer, and diabetes and provided data on alcohol consumption at baseline.

MAIN OUTCOME MEASURE

Type 2 DM diagnosed after randomization.

RESULTS

Among 20 951 physicians, 766 cases of incident DM were reported over an average follow-up period of 12.1 years. After adjustment for age, randomized treatment assignment, smoking, physical activity, and body mass index, the relative risk estimates and 95% confidence intervals for those reporting alcohol use of rarely/ never, 1 to 3 drinks per month, 1 drink per week, 2 to 4 drinks per week, 5 to 6 drinks per week, and 1 or more drinks per day were 1.00 (referent), 1.03 (0.80-1.33), 0.89 (0.70-1.14), 0.74 (0.59-0.93), 0.67 (0.51-0.89), and 0.57 (0.45-0.73), respectively (linear trend, P<.001). Additional adjustment for baseline history of hypertension, high cholesterol level, or parental history of myocardial infarction or family history of diabetes (data collected at 9 years) did not materially alter the results. These associations persisted in analyses stratified by age, smoking status, body mass index, physical activity, and family history of DM.

CONCLUSION

These data indicate that apparently healthy men who self-select for light to moderate alcohol consumption have a decreased subsequent risk of type 2 DM.

Blood levels of homocysteine and increased risks of cardiovascular disease: causal or casual?

BACKGROUND

Accumulating data from epidemiological studies suggest that individuals with elevated blood levels of homocysteine have increased risks of cardiovascular disease. We reviewed the currently available evidence of an association between homocysteine and cardiovascular disease and examined whether the strength of the evidence varies according to study design.

METHODS

We used a computerized MEDLINE literature search, 1966 through September 1998, to identify all epidemiological studies that examined the relationship of homocysteine level with risks of coronary heart or cerebrovascular disease. Two measures of plasma homocysteine level and its association with risk of cardiovascular disease were extracted: mean homocysteine level in cases and controls, and relative risk of cardiovascular disease for elevated homocysteine level.

RESULTS

A total of 43 studies were reviewed. Most crosssectional and case-control studies indicated higher mean homocysteine levels (either fasting or after methionine load) and/or a greater frequency of elevated homocysteine level in persons with cardiovascular disease as compared with persons without cardiovascular disease. Results of most prospective studies, however, indicated smaller or no association. The few prospective studies that reported a positive association between homocysteine level and risks of cardiovascular disease included patients with preexisting vascular disease.

CONCLUSIONS

In contrast to cross-sectional and case-control studies, results of prospective studies indicated less or no predictive ability for plasma homocysteine in cardiovascular disease. Instead, elevated homocysteine level may be an acute-phase reactant that is predominantly a marker of atherogenesis, or a consequence of other factors more closely linked to risks of cardiovascular disease. Randomized trials are necessary to test reliably whether lowering homocysteine levels will decrease risks of cardiovascular disease.

Male pattern baldness and coronary heart disease: the Physicians' Health Study

OBJECTIVE

To examine the association between male pattern baldness and the risk of coronary heart disease (CHD) events.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study among 22,071 US male physicians aged 40 to 84 years enrolled in the Physicians' Health Study. Of these, 19,112 were free of CHD at baseline and completed a questionnaire at the 11-year follow-up concerning their pattern of hair loss at age 45 years. Response options included no hair loss, frontal baldness only, or frontal baldness with mild, moderate, or severe vertex baldness.

MAIN OUTCOME MEASURES

Coronary heart disease events defined as nonfatal myocardial infarction (MI), angina pectoris, and/or coronary revascularization.

RESULTS

During 11 years of follow-up, we documented 1446 CHD events in this cohort. Compared with men with no hair loss, those with frontal baldness had an age-adjusted relative risk (RR) of CHD of 1.09 (95% confidence interval [CI], 0.94-1.25), while those with mild, moderate, or severe vertex baldness had RRs of 1.23 (95% CI, 1.05-1.43), 1.32 (95% CI, 1.10-1.59), and 1.36 (95% CI, 1.11-1.67), respectively (P for trend, <.001). Multivariate adjustment for age, parental history of MI, height, body mass index (weight in kilograms divided by the square of the height in meters as a continuous variable), smoking, history of hypertension, diabetes, high cholesterol level, physical activity, and alcohol intake did not materially alter these associations. Results were similar when nonfatal MI, angina, and coronary revascularization were examined separately, and when events were analyzed among men older and younger than 55 years at baseline. Vertex baldness was more strongly associated with CHD risk among men with hypertension (multivariate RR, 1.79; 95% CI, 1.31-2.44) or high cholesterol levels (multivariate RR, 2.78; 95% CI, 1.09-7.12).

CONCLUSION

Vertex pattern baldness appears to be a marker for increased risk of CHD events, especially among men with hypertension or high cholesterol levels.

Light-to-moderate alcohol consumption and mortality in the Physicians' Health Study enrollment cohort

OBJECTIVES

This study examined the relationship between light-to-moderate alcohol consumption and cause-specific mortality.

BACKGROUND

Previous studies suggest a J-shaped relation between alcohol and total mortality in men. A decrease in cardiovascular disease (CVD) mortality without a significant increase in other causes of mortality may explain the overall risk reduction at light-to-moderate levels.

METHODS

We conducted a prospective cohort study of 89,299 U.S. men from the Physicians' Health Study enrollment cohort who were 40 to 84 years old in 1982 and free of known myocardial infarction, stroke, cancer or liver disease at baseline. Usual alcohol consumption was estimated by a limited food frequency questionnaire.

RESULTS

There were 3,216 deaths over 5.5 years of follow-up. We observed a U-shaped relationship between alcohol consumption and total mortality. Compared with rarely/never drinkers, consumers of 1, 2 to 4 and 5 to 6 drinks per week and 1 drink per day had significant reductions in risk of death (multivariate relative risks [RRs] of 0.74, 0.77, 0.78 and 0.82, respectively) with no overall benefit or harm detected at the > or =2 drinks per day level (RR = 0.95; 95% confidence interval (CI), 0.79 to 1.14). The relationship with CVD mortality was inverse or L-shaped with apparent risk reductions even in the highest category of > or =2 drinks per day (RR = 0.76; 95% CI, 0.57 to 1.01). We found no clear harm or benefit for total or common site-specific cancers. For remaining other cancers, there was a nonsignificant 28% increased risk for those consuming > or =2 drinks per day.

CONCLUSIONS

These data support a U-shaped relation between alcohol and total mortality among light-to-moderate drinking men. The U-shaped curve may reflect an inverse association for CVD mortality, no association for common site-specific cancers and a possible positive association for less common cancers.

Light-to-moderate alcohol consumption and the risk of stroke among U.S. male physicians

BACKGROUND

Several studies have shown U- or J-shaped relations between alcohol consumption and the risk of stroke. We evaluated the effect of light-to-moderate alcohol intake on the risk of stroke, with separate analyses of ischemic stroke and hemorrhagic stroke.

METHODS

Our analyses were based on a prospective cohort study of 22,071 male physicians, 40 to 84 years old, who were participating in the Physicians' Health Study. At base line, the participants reported that they had no history of stroke, transient ischemic attack, or myocardial infarction and were free of cancer. Alcohol intake, reported by 21,870 participants at base line, ranged from none or almost none to two or more drinks per day.

RESULTS

During an average of 12.2 years of follow-up, 679 strokes were reported. As compared with participants who had less than one drink per week, those who drank more had a reduced overall risk of stroke (relative risk, 0.79; 95 percent confidence interval, 0.66 to 0.94) and a reduced risk of ischemic stroke (relative risk, 0.77; 95 percent confidence interval, 0.63 to 0.94). There was no statistically significant association between alcohol consumption and hemorrhagic stroke. The overall relative risks of stroke for the men who had one drink per week, two to four drinks per week, five or six drinks per week, or one or more drinks per day were 0.78 (95 percent confidence interval, 0.59 to 1.04), 0.75 (95 percent confidence interval, 0.58 to 0.96), 0.83 (95 percent confidence interval, 0.62 to 1.11), and 0.80 (95 percent confidence interval, 0.64 to 0.99), respectively, in an analysis in which we controlled for major risk factors for stroke.

CONCLUSIONS

Light-to-moderate alcohol consumption reduced the overall risk of stroke and the risk of ischemic stroke in men. The benefit is apparent with as little as one drink per week. Greater consumption, up to one drink per day, does not increase the observed benefit.

Moderate alcohol consumption and the risk of sudden cardiac death among US male physicians

BACKGROUND

Individuals who consume high amounts of alcohol (>5 drinks/d) have increased risks of ventricular arrhythmia and sudden cardiac death (SCD). However, the relationship is less clear for drinkers of light-to-moderate amounts.

METHODS AND RESULTS

We prospectively assessed whether light-to-moderate alcohol drinkers have a decreased risk of SCD among 21 537 male participants in the Physicians Health Study who were free of self-reported cardiovascular disease and provided complete information on alcohol intake at study entry. Over 12 years of follow-up, 141 SCDs were confirmed. After control for multiple confounders, men who consumed 2 to 4 drinks/wk (RR=0.40; 95% CI, 0.22 to 0.75; P=0.004) or 5 to 6 drinks/wk (RR=0.21; 95% CI, 0.08 to 0.56; P=0.002) at baseline had significantly reduced risks of SCD compared with those who rarely or never consumed alcohol. The relationship for SCD was U-shaped (P=0. 002), with the risk approaching unity at >/=2 drinks/d. In contrast, the relationship of alcohol intake and nonsudden CHD death was L-shaped or linear (P for trend=0.02).

CONCLUSIONS

In these prospective data, men who consumed light-to-moderate amounts of alcohol (2 to 6 drinks/wk) had a significantly reduced risk of SCD compared with those who rarely or never consumed alcohol.

A prospective study of alcohol consumption and the risk of age-related macular degeneration

PURPOSE

Vascular risk factors, including alcohol intake, have been hypothesized to play a role in the development of age-related macular degeneration (AMD). We examined the relationship of alcohol intake with AMD in the Physicians' Health Study (PHS).

METHODS

The PHS was a randomized trial of aspirin and beta-carotene among 22,071 U.S. male physicians age 40 to 84 years at entry. A total of 21,041 physicians with complete data on alcohol consumption and no AMD at baseline were included in this analysis. Proportional hazards models were used to estimate relative risks (RR) and 95% confidence interval (CI).

RESULTS

During an average follow-up period of 12.5 years, 278 physicians were confirmed by medical record review to have incident AMD resulting in vision loss ( acuity 20/30 or worse). After adjusting for age, randomized treatment assignment, and other potential risk factors, the RR for > or = 1 drink/week versus < 1 drink/week was 0.97 (CI: 0.78-1.21). For categories of alcohol intake, the RRs for those reporting alcohol consumption of < 1 drink/week, 1 drink/week, 2-4 drinks/week, 5-6 drinks/week, and > or = 1 drink/day were 1.00 (referent), 1.00 (0.65-1.55), 0.68 (0.44-1.04), 1.32 (0.89-1.95), and 1.27 (0.93-1.73), respectively.

CONCLUSIONS

These prospective data indicate that alcohol intake is not appreciably associated with the risk of incident AMD. However, the width of the confidence intervals are compatible with a possible small effect (reduction or increase) in risk for low to moderate levels of alcohol intake, which warrant further investigation.

Prospective cohort study of antioxidant vitamin supplement use and the risk of age-related maculopathy

In a prospective cohort study, the authors examined whether self-selection for antioxidant vitamin supplement use affects the incidence of age-related maculopathy. The study population consisted of 21,120 US male physician participants in the Physicians' Health Study I who did not have a diagnosis of age-related maculopathy at baseline (1982). During an average of 12.5 person-years of follow-up, a total of 279 incident cases of age-related maculopathy with vision loss to 20/30 or worse were confirmed by medical record review. In multivariate analysis, as compared with nonusers of supplements, persons who used vitamin E supplements had a possible but nonsignificant 13% reduced risk of age-related maculopathy (relative risk = 0.87, 95 percent confidence interval (CI) 0.53-1.43), while users of multivitamins had a possible but nonsignificant 10% reduced risk (relative risk = 0.90, 95% CI 0.68-1.19). Users of vitamin C supplements had a relative risk of 1.03 (95% CI 0.71-1.50). These observational data suggest that among persons who self-select for supplemental use of antioxidant vitamin C or E or multivitamins, large reductions in the risk of age-related maculopathy are unlikely. Randomized trial data are accumulating to enable reliable detection of the existence of more plausible small-to-moderate benefits of these agents alone and in combination on age-related maculopathy.

Low-dose aspirin and risk of cataract and subtypes in a randomized trial of U.S. physicians

PURPOSE

To examine whether low-dose aspirin (325 mg on alternate days) reduces the risk of age-related cataract and subtypes. This report extends previous findings, including both subtypes and additional newly identified incident cases since the earlier report.

METHODS

All 20,979 participants in the Physicians' Health Study, a randomized trial of aspirin and beta-carotene among U.S. male physicians age 40-84 in 1982, who did not report cataract at baseline were included. Average follow-up was five years. The main outcome measure was incident, age-related cataract responsible for a reduction in best-corrected visual acuity to 20/30 or worse, based on self-report confirmed by medical record review.

RESULTS

501 age-related cataracts were diagnosed during follow-up, including 416 with nuclear sclerosis and 212 with a posterior subcapsular component; 318 cataracts progressed to surgical extraction. Overall, there were 245 cataracts in the aspirin group and 256 in the placebo group (relative risk [RR], 0.94; 95% confidence interval [CI], 0.79 to 1.13; P = 0.52). Cataract extractions were 19% less frequent in the aspirin than in the placebo group (RR, 0.81; 95% CI, 0.65 to 1.01; P = 0.06). In subgroup analyses of subtypes, aspirin takers had a lower risk of posterior subcapsular cataract (RR, 0.74; 95% CI, 0.57 to 0.98; P = 0.03) but not nuclear sclerosis (RR, 0.96; 95% CI, 0.79 to 1.16; P = 0.65) cataract.

CONCLUSIONS

Overall, these randomized trial data tend to exclude a large benefit of five years of low-dose aspirin therapy on cataract development and extraction. The data are compatible with a modest benefit on cataract extraction for this duration of aspirin therapy. Subgroup analyses raise the possibility of a modest, but potentially important, protective effect of aspirin on posterior subcapsular cataract, a particularly disabling subtype.

Fish consumption and risk of sudden cardiac death

CONTEXT

Dietary fish intake has been associated with a reduced risk of fatal cardiac end points, but not with nonfatal end points. Dietary fish intake may have a selective benefit on fatal arrhythmias and therefore sudden cardiac death.

OBJECTIVE

To investigate prospectively the association between fish consumption and the risk of sudden cardiac death.

DESIGN

Prospective cohort study.

SETTING

The US Physicians' Health Study.

PATIENTS

A total of 20 551 US male physicians 40 to 84 years of age and free of myocardial infarction, cerebrovascular disease, and cancer at baseline who completed an abbreviated, semiquantitative food frequency questionnaire on fish consumption and were then followed up to 11 years.

MAIN OUTCOME MEASURE

Incidence of sudden cardiac death (death within 1 hour of symptom onset) as ascertained by hospital records and reports of next of kin.

RESULTS

There were 133 sudden deaths over the course of the study. After controlling for age, randomized aspirin and beta carotene assignment, and coronary risk factors, dietary fish intake was associated with a reduced risk of sudden death, with an apparent threshold effect at a consumption level of 1 fish meal per week (P for trend=.03). For men who consumed fish at least once per week, the multivariate relative risk of sudden death was 0.48 (95% confidence interval, 0.24-0.96; P=.04) compared with men who consumed fish less than monthly. Estimated dietary n-3 fatty acid intake from seafood also was associated with a reduced risk of sudden death but without a significant trend across increasing categories of intake. Neither dietary fish consumption nor n-3 fatty acid intake was associated with a reduced risk of total myocardial infarction, nonsudden cardiac death, or total cardiovascular mortality. However, fish consumption was associated with a significantly reduced risk of total mortality.

CONCLUSION

These prospective data suggest that consumption of fish at least once per week may reduce the risk of sudden cardiac death in men.

Familial aggregation of age-related maculopathy

PURPOSE

To determine whether age-related maculopathy aggregates in families by evaluating whether its prevalence is higher among relatives of case subjects with age-related maculopathy compared with relatives of control subjects without age-related maculopathy.

METHODS

Individuals with (n = 119) and without (n = 72) age-related maculopathy were identified. First-degree relatives of case and control probands (parents, siblings, or offspring) 40 years of age or older were asked whether they had ever been diagnosed with macular degeneration. Medical records of 177 case and 146 control relatives confirmed the presence or absence of age-related maculopathy.

RESULTS

The prevalence of medical-record confirmed age-related maculopathy was significantly higher among first-degree relatives of case probands (23.7%) compared with first-degree relatives of control probands (11.6%) with an age- and sex-adjusted odds ratio (OR), 2.4; 95% confidence interval (CI), 1.2 to 4.7; P = .013. Relatives of 78 case probands with exudative disease had a significantly higher prevalence of maculopathy (26.9%) compared with relatives of the 72 unaffected control probands (11.6%) (adjusted OR, 3.1; 95% CI, 1.5 to 6.7; P = .003), whereas the prevalence of age-related maculopathy among relatives of 41 probands with dry maculopathy (19.2%) was slightly but not significantly higher (adjusted OR, 1.5; 95% CI, 0.6 to 3.7; P = .36).

CONCLUSIONS

The prevalence of age-related maculopathy among first-degree relatives of subjects with age-related maculopathy, particularly with exudative disease, is greater than among first-degree relatives of subjects without this disease. Results suggest that macular degeneration has a familial component and that genetic or shared environmental factors, or both, contribute to its development.

A prospective study of cigarette smoking and risk of age-related macular degeneration in men

OBJECTIVE

To examine the association between cigarette smoking and the incidence of age-related macular degeneration (AMD) in men.

DESIGN

Prospective cohort study with average person-years of follow-up for AMD of 12.2 years.

PARTICIPANTS

A total of 21 157 US male physicians participating in the Physicians' Health Study who did not have a diagnosis of AMD at baseline, were followed for at least 7 years, and had known levels of baseline smoking. Based on information reported at baseline, 11% were current smokers, 39% were past smokers, and 50% were never smokers.

MAIN OUTCOME MEASURE

Incident AMD, defined as a self-report that was confirmed by medical record, review, first diagnosed after randomization, and responsible for vision loss to 20/30 or worse.

RESULTS

A total of 268 incident cases of AMD with vision loss were confirmed. In multivariate analysis, current smokers of 20 or more cigarettes per day, compared with never smokers, had an increased risk of AMD (relative risk [RR], 2.46; 95% confidence interval [CI], 1.60-3.79). Past smokers had a modest elevation in risk of AMD (RR, 1.30; 95% CI, 0.99-1.70). For current smokers of fewer than 20 cigarettes per day, there was a nonsignificant 26% increased risk of AMD (RR, 1.26; 95% CI, 0.61-2.59).

CONCLUSIONS

These prospective data provide support for the hypothesis that cigarette smoking increases the risk of developing AMD.

Reproducibility of a food frequency questionnaire for use in ocular research. Eye Disease Case-Control Study Group

PURPOSE

Assessment of nutritional factors was an ancillary component of the Eye Disease Case-Control Study sponsored by the National Eye Institute. This multicenter study was designed to evaluate the role of potential risk factors for a number of retinal disorders. The authors examined the reproducibility of the food frequency questionnaire used in this study.

METHODS

A semiquantitative food frequency questionnaire, designed for use in this study, was self-administered by participants. To evaluate the reproducibility of this dietary questionnaire, a subsample of 325 participants completed a second questionnaire within 12 to 18 months of the first. Pearson product-moment coefficient was used to assess the correlation between the log of calorie-adjusted nutrient scores, and Spearman correlations were used for specific food items.

RESULTS

The responses for intake of 60 food items in the questionnaire were reasonably consistent. Correlation coefficients for individual food items ranged from 0.40 to 0.82. Pearson correlation coefficients for logs of calorie-adjusted intake of nutrients ranged from 0.38 to 0.75. Nutrients of interest in eye disease include total protein (r = 0.57), total fat (r = 0.71), saturated fats (r = 0.69), carotene (r = 0.61), vitamin C (with supplements, r = 0.66), vitamin E (with supplements, r = 0.69), and zinc (with supplements, r = 0.43). Partial correlations controlling for age, sex, and clinical center were similar.

CONCLUSIONS

These findings indicate that the food frequency questionnaire used in this study provides reasonably reproducible dietary information.

Occupation and risk of uveal melanoma. An exploratory study

BACKGROUND

Little is known about the cause of uveal melanoma, the most common primary intraocular malignant lesion in adults. This population-based case-control study evaluated occupational exposures.

METHODS

One hundred ninety-seven newly diagnosed cases of uveal melanoma participated. Approximately two control subjects matched for age, sex, and telephone exchange area were selected for each case by random-digit dialing. Data were collected by a structured telephone interview. Two systems of occupational coding were used: an occupation-exposure linkage system and the Bureau of Census data. Conditional logistic regression for matched studies was used to examine various occupational exposures while controlling for previously reported potential confounders and for family income. The occupation-exposure matrix was used to define clusters of cases exposed to a particular chemical group from various occupations.

RESULTS

Odds ratios were elevated for agriculture and farming work for both industry and occupation; this was consistent across both classification systems. Elevated odds ratios also were found for occupations involving machine operations, fabrication, assembling, equipment cleaning, and exposure to metal industries. Exposure to alkylating agents and phenols was associated with a lower risk compared with all other exposures. Several self-reported exposures also were studied. Exposures associated with elevated odds ratios were inks, insecticides, gases, radioactive substances, polybromated biphenyls, and chemical solvents.

CONCLUSIONS

This exploratory study suggests various occupational associations for uveal melanoma and areas for future research.