Eligibility for Obesity Treatment and Risk of Mortality in Men

Objective: To evaluate the risk of all‐cause and cardiovascular disease (CVD) mortality associated with each outcome of the NIH obesity treatment algorithm and to examine the effects of cardiorespiratory fitness on the risk of mortality associated with these outcomes. Research Methods and Procedures: The NIH obesity treatment algorithm was applied to 18, 666 men (20 to 64 years of age) from the Aerobics Center Longitudinal Study in Dallas, TX, examined between 1979 and 1995. Risk of all‐cause and CVD mortality was assessed using Cox proportional hazards regression. Results: A total of 7029 men (37.7%) met the criteria for needing weight loss treatment [overweight (BMI = 25 to 29.9 kg/m² or WC > 102 cm) with ≥2 CVD risk factors or obese (BMI ≥ 30 kg/m²)]. Mortality surveillance through 1996 identified 435 deaths (151 from CVD) during 191, 364 man‐years of follow‐up. Compared with the normal weight reference group, the hazard ratios (95% confidence interval) for death from all causes were 0.63 (0.45 to 0.88), 1.23 (0.98 to 1.54), 1.05 (0.60 to 1.85), and 1.71 (1.64 to 2.31) for men who were overweight with <2 CVD risk factors, overweight with ≥2 CVD risk factors, obese with <2 CVD risk factors, and obese with ≥2 CVD risk factors, respectively. Corresponding hazard ratios for CVD mortality were 0.72 (0.38 to 1.37), 1.67 (1.12 to 2.50), 1.69 (0.67 to 4.30), and 3.31 (2.07 to 5.30). Including physical fitness as a covariate significantly attenuated all risk estimates. Discussion: The NIH obesity treatment algorithm is useful in identifying men at increased risk of premature mortality; however, including an assessment of fitness would help improve risk stratification among all groups of patients.     

Lifetime socioeconomic position and mortality: prospective observational study.

OBJECTIVES: To assess the influence of socioeconomic position over a lifetime on risk factors for cardiovascular disease, on morbidity, and on mortality from various causes. DESIGN: Prospective observational study with 21 years of follow up. Social class was determined as manual or non-manual at three stages of participants'' lives: from the social class of their father''s job, the social class of their first job, and the social class of their job at the time of screening. A cumulative social class indicator was constructed, ranging from non-manual social class at all three stages of life to manual social class at all three stages. SETTING: 27 workplaces in the west of Scotland. PARTICIPANTS: 5766 men aged 35-64 at the time of examination. MAIN OUTCOME MEASURES: Prevalence and level of risk factors for cardiovascular disease; morbidity; and mortality from broad causes of death. RESULTS: From non-manual social class locations at all three life stages to manual at all stages there were strong positive trends for blood pressure, body mass index, current cigarette smoking, angina, and bronchitis. Inverse trends were seen for height, cholesterol concentration, lung function, and being an ex-smoker. 1580 men died during follow up. Age adjusted relative death rates in comparison with the men of non-manual social class locations at all three stages of life were 1.29 (95% confidence interval 1.08 to 1.56) in men of two non-manual and one manual social class; 1.45 (1.21 to 1.73) in men of two manual and one non-manual social class; and 1.71 (1.46 to 2.01) in men of manual social class at all three stages. Mortality from cardiovascular disease showed a similar graded association with cumulative social class. Mortality from cancer was mainly raised among men of manual social class at all three stages. Adjustment for a wide range of risk factors caused little attenuation in the association of cumulative social class with mortality from all causes and from cardiovascular disease; greater attenuation was seen in the association with mortality from non-cardiovascular, non-cancer disease. Fathers having a manual [corrected] occupation was strongly associated with mortality from cardiovascular disease: relative rate 1.41 (1.15 to 1.72). Participants'' social class at the time of screening was more strongly associated than the other social class indicators with mortality from cancer and from non-cardiovascular, non-cancer causes. CONCLUSIONS: Socioeconomic factors acting over the lifetime affect health and risk of premature death. The relative importance of influences at different stages varies for the cause of death. Studies with data on socioeconomic circumstances at only one stage of life are inadequate for fully elucidating the contribution of socioeconomic factors to health and mortality risk.     

Neuromuscular economy, strength, and endurance in healthy elderly men

Declines in muscular strength resulting from reduced neural activity may influence the reduction in aerobic capacity in older men. However, there has been little investigation into the relationship between muscular strength and economy of movement during aerobic exercise in elderly subjects. Thus, the purpose of this study was to investigate the possible relationship between strength, aerobic performance, and neuromuscular economy in older men. Twenty-eight aged men (65 ± 4 years old) were evaluated in dynamic (1 repetition maximum test), isometric strength (maximal voluntary contraction), and rate of force development. Peak oxygen uptake, maximal workload, and ventilatory threshold were determined during a ramp protocol on a cycle ergometer. Throughout the same protocol, the neuromuscular economy (electromyographic signal) of the vastus lateralis was measured. Significant correlations were found between muscular strength, cardiorespiratory fitness, and neuromuscular economy (r = 0.43-0.64, p < 0.05). Our results suggest that cardiorespiratory capacity and economy of movement are associated with muscular strength during aging.     

A Lower Level of Forced Expiratory Volume in 1 Second Is a Risk Factor for All-Cause and Cardiovascular Mortality in a Japanese Population: The Takahata Study

Chronic obstructive pulmonary disease is a known risk factor for cardiovascular death in Western countries. Because Japan has a low cardiovascular death rate, the association between a lower level of forced expiratory volume in 1 s (FEV₁) and mortality in Japan’s general population is unknown. To clarify this, we conducted a community-based longitudinal study. This study included 3253 subjects, who received spirometry from 2004 to 2006 in Takahata, with a 7-year follow-up. The causes of death were assessed on the basis of the death certificate. In 338 subjects, airflow obstruction was observed by spirometry. A total of 127 subjects died. Cardiovascular death was the second highest cause of death in this population. The pulmonary functions of the deceased subjects were significantly lower than those of the subjects who were alive at the end of follow-up. The relative risk of death by all causes, respiratory failure, lung cancer, and cardiovascular disease was significantly increased with airflow obstruction. The Kaplan–Meier analysis showed that all-cause and cardiovascular mortality significantly increased with a worsening severity of airflow obstruction. After adjusting for possible factors that could influence prognosis, a Cox proportional hazard model analysis revealed that a lower level of FEV₁ was an independent risk factor for all-cause and cardiovascular mortality (per 10% increase; hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.82–0.98; and HR, 0.72; 95% CI, 0.61–0.86, respectively). In conclusion, airflow obstruction is an independent risk factor for all-cause and cardiovascular death in the Japanese general population. Spirometry might be a useful test to evaluate the risk of cardiovascular death and detect the risk of respiratory death by lung cancer or respiratory failure in healthy Japanese individuals.     

Non-fasting serum triglyceride concentration and mortality from coronary heart disease and any cause in middle aged Norwegian women.

OBJECTIVE--To study the association between non-fasting serum triglyceride concentrations and mortality in women from coronary and cardiovascular disease and all causes. DESIGN--Follow up by ambulatory teams of men and women who underwent cardiovascular screening for a mean of 14.6 years. SETTING--National health screening service in Norway. SUBJECTS--25,058 men and 24,535 women aged 35-49 years. MAIN OUTCOME MEASURE--Predictive value of non-fasting serum triglyceride concentrations. RESULTS--At initial screening total serum cholesterol concentration, serum triglyceride concentration, blood pressure, height, and weight were measured, and self reported information about smoking habits, physical activity, and time since last meal were recorded. During subsequent follow up 108 women died from coronary heart disease, 238 from cardiovascular diseases, and 931 from all causes. In women mortality increased steadily with increasing triglyceride concentration for all three causes of death. With the proportional hazards model and adjustment for age, systolic blood pressure, total cholesterol concentration, time since last meal, and number of cigarettes a day the relative risk between triglyceride concentration > or = 3.5 mmol/l and < 1.5 mmol/l was 4.7 (95% confidence interval 2.5 to 8.9) for deaths from coronary heart disease, 3.0 (1.9 to 4.8) for deaths from cardiovascular disease, 2.3 (1.8 to 2.9) for total deaths in all women. CONCLUSIONS--A raised non-fasting concentration of triglycerides is an independent risk factor for mortality from coronary heart disease, cardiovascular disease, and any cause mortality among middle aged Norwegian women in contrast to what is seen in men.     

Cardiorespiratory fitness, different measures of adiposity, and cancer mortality in men

Objective: The purpose was to examine the prospective relationship among cardiorespiratory fitness level (CRF), different measures of adiposity, and cancer mortality in men. Research Methods and Procedures: Participants were 38,410 apparently healthy men who completed a comprehensive baseline health examination between 1970 and 2001. Clinical measures included BMI, waist circumference (WC), percent body fat, and CRF quantified as duration of a maximal treadmill exercise test. Participants were divided into fifths of CRF, BMI, WC, and percent body fat. Hazard ratios were computed with Cox regression analysis. Results: During a mean follow‐up period of 17.2 ± 7.9 years, 1037 cancer deaths occurred. Adjusted hazard ratios across incremental BMI quintiles were 1.0, 1.23, 1.15, 1.39, and 1.72; those of WC were 1.0, 1.05, 1.03, 1.31, and 1.64; those of percent body fat were 1.0, 1.24, 1.17, 1.23, and 1.50; and those of CRF were 1.0, 0.70, 0.67, 0.70, and 0.49 (trend p < 0.01 for each). Further adjustment for CRF eliminated the significant trend in mortality risk across percent body fat groups and attenuated the trend in risk across BMI and WC groups. Adjustment of CRF for adiposity measures had little effect on mortality risk. When grouped into categories of fit and unfit (upper 80% and lower 20% of CRF distribution, respectively), mortality rates (per 10,000 man‐years) were significantly lower in fit compared with unfit men within each stratum of BMI, WC, and percent body fat. Discussion: Higher levels of CRF are associated with lower cancer mortality risk in men, independently of several adiposity measures.     

Plasma cholesterol,coronary heart disease,and cancer in the Renfrew and Paisley survey.

The relation between plasma cholesterol concentration and mortality from coronary heart disease, incidence of and mortality from cancer, and all cause mortality was studied in a general population aged 45-64 living in the west of Scotland. Seven thousand men (yielding 653 deaths from coronary heart disease, 630 new cases of cancer, and 463 deaths from cancer) and 8262 women (322 deaths from coronary heart disease, 554 new cases of cancer, and 395 deaths from cancer) were examined initially in 1972-6 and followed up for an average of 12 years. All cause mortality was not related to plasma cholesterol concentration. This was largely a consequence of a positive relation between cholesterol values and mortality from coronary heart disease being balanced by inverse relations between cholesterol and cancer and between cholesterol and other causes of death. These changes were highly significant for coronary heart disease and cancer in men and significant for coronary heart disease and other causes of death in women. The inverse association between cholesterol concentration and cancer in men was strongest for lung cancer, was not merely a function of the age at which a subject died, was present for the incidence of cancer as well as mortality from cancer, and persisted when new cases or deaths occurring within the first four years of follow up were excluded from the analysis.     

Are low cholesterol values associated with excess mortality?

The relation between cholesterol concentration and mortality was studied prospectively over 17 years in 630 New Zealand Maoris aged 25-74. The dead or alive state of each person was determined in 1981. The causes of death were divided into three categories: cancer, cardiovascular disease, and "other." Using univariate and both linear and non-linear multivariate methods of analysis for survivorship data, significant inverse relations with serum cholesterol were found for total mortality in women, for mortality from cancer in men and women, and for other causes of mortality in both men and women. The inverse and non-linear association with total mortality in women remained significant when deaths in the first five years of follow up were excluded. This suggests that the association was not explained by undetected illness causing low cholesterol concentrations at the time of initial examination.     

Muscular Strength Is Inversely Related to Prevalence and Incidence of Obesity in Adult Men

The purpose of the study was to determine the relation between quintiles of muscular strength after adjustment for age and body weight, and excessive body fat (EBF) and excessive abdominal fat (EAF) when controlling for cardiorespiratory fitness (CRF) and other potential confounders. A two‐phased cross‐sectional and longitudinal study was conducted assessing the prevalence and incidence of EBF and EAF across quintiles of muscular strength. The sample included 3,258 men (mean age = 42.2 ± 8.9; weight (kg) = 81.2 ± 11.0; BMI = 25.3 ± 2.9; %fat = 19.4 ± 5.8; waist girth (cm) = 91.2 ± 9.0) who completed at least two clinical examinations as part of the Aerobics Center Longitudinal Study (ACLS). Muscular strength was assessed with tests of upper and lower body muscular strength using rack‐mounted weights with participants placed into strength quintiles. CRF was measured by a modified Balke treadmill test, %fat via underwater weighing or seven‐site skinfold measurements, and waist girth measured at the level of the umbilicus. EBF was defined as ≥25% and EAF was defined as >102 cm. There was a strong inverse gradient across quintiles of muscular strength for prevalence and incidence of EBF and EAF (P trend <0.01, each). With the lowest quintile serving as the referent, reductions in risk of EBF and EAF exceeded 70% for the highest strength quintile. Evidence suggests muscular strength may provide protection from EBF and EAF and their related comorbidities.     

Respiratory symptoms as predictors of 27 year mortality in a representative sample of British adults.

OBJECTIVE--To examine associations between reported respiratory symptoms (as elicited by questionnaire) and subsequent mortality. DESIGN--Prospective cohort study. SETTING--92 General practices in Great Britain. PARTICIPANTS--A nationally representative sample of 1532 British men and women aged between 40 and 64. MAIN OUTCOME MEASURES--Mortality from all causes, cardiovascular disease, lung cancer, and chronic bronchitis. RESULTS--Subjects were interviewed in 1958 regarding various respiratory symptoms (including cough, phlegm, breathlessness, and wheeze) by using a questionnaire which formed the basis of the Medical Research Council''s questionnaire on respiratory symptoms. By the end of 1985, 889 deaths had been reported, including 51 in men due to chronic bronchitis. After adjustment for differences in age and smoking habits death rates from chronic bronchitis in men who reported symptoms were greater than those in men who did not for each of the symptoms examined. The adjusted mortality ratios were 3.4 (95% confidence interval 1.8 to 6.5) for morning cough, 3.7 (2.0 to 6.9) for morning phlegm, 6.4 (3.0 to 13.8) for breathlessness when walking on the level, and 10.5 (4.4 to 24.6) for wheeze most days or nights. Mortality ratios were also significantly raised for four episodic symptoms not usually included in more recent respiratory symptom questionnaires--namely, occasional wheeze (mortality ratio 6.0; 95% confidence interval, 2.4 to 15.1), weather affects chest (5.7; 3.1 to 10.3), breathing different in summer (4.9; 2.8 to 8.6), and cold usually goes to chest (3.7; 2.0 to 6.8). The excess mortality associated with these symptoms remained significant after further adjustment for breathlessness or phlegm. Ratios for all cause mortality in men and women were also significantly raised for most respiratory symptoms, death rates being some 20-50% higher in people reporting symptoms after adjustment for age, sex, and smoking. Breathlessness was the only symptom significantly associated with excess mortality from cardiovascular disease (mortality ratio 1.4 (95% confidence interval 1.0 to 1.9) for breathlessness when walking on the level). Ratios were generally around unity and not significant for mortality due to lung cancer. CONCLUSIONS--The results suggest that episodic symptoms, which often do not appear in standard respiratory questionnaires, predict subsequent mortality from chronic obstructive airways disease. This supports the hypothesis that reversible airflow obstruction may be a precursor of progressive and irreversible decline in ventilatory function.     

Association between muscular strength and metabolic risk in Japanese women, but not in men

We examined whether cardiorespiratory fitness (maximal oxygen uptake, VO(2)max) and muscular strength (grip strength) are associated with individual and clustered metabolic risk factors independently of abdominal adiposity in Japanese men (n=110) and women (n=110) aged 20-69 years. Blood pressure, triglycerides (TG), HDL cholesterol, and fasting plasma glucose (FPG) were assessed and metabolic risk score was calculated, which is the sum of the z scores for each individual risk factor. Waist circumference was measured and the area of visceral fat was assessed by MRI. Multiple linear regression analysis revealed that VO(2)max was inversely associated with TG in men (p<0.05) and grip strength was negatively associated with FPG and metabolic risk score in women (p<0.001 and p<0.05, respectively), independently of waist circumference. Adjusting for visceral fat instead of waist circumference, similar results were obtained in women (p<0.01 and p<0.05, respectively), but the association between VO(2)max and TG in men was attenuated to nonsignificant. This cross-sectional study demonstrates that muscular strength is inversely associated with plasma glucose levels and clustered metabolic risk factors independently of abdominal adiposity in Japanese women, but not in men.     

High serum insulin-like growth factor binding protein-1 is associated with increased cardiovascular mortality in elderly men.

Insulin-like growth factor binding protein-1 (IGFBP-1) has been implicated in the development of cardiovascular disease, but it is not known whether IGFBP-1 is related to cardiovascular mortality. We examined the relation of circulating IGFBP-1 to death from coronary heart disease, cardiovascular disease, and all causes in a cohort study consisting of 622 men aged 65 - 84 years, at baseline in 1984. Fasting serum IGFBP-1 and other risk factors were measured in 1984 and 1989. Cardiovascular events for those who died between 1984 and 1995 were analyzed, and cardiovascular diagnoses were coded centrally according to standardized procedures. Of the 622 men, 358 died between 1984 and 1995; 160 deaths were due to cardiovascular causes, 113 of which were coronary deaths. High fasting serum IGFBP-1 concentration (> 75 percentile) in 1984 was associated with increased five-year total mortality (OR 2.05, 95 % CI 1.41 - 2.99; p < 0.0002), cardiovascular mortality (OR 2.20, 95 % CI 1.37 - 3.50; p < 0.0009) and coronary heart disease mortality (OR 2.29, 95 % CI 1.35 - 3.88; p < 0.002). After adjustment for age, high serum IGFBP-1 concentrations still carried an increased risk of total mortality due to (OR 1.73, 95 % CI 1.16 - 2.59; p < 0.007), cardiovascular (OR 1.91 95 % CI 1.18 - 3.09; p < 0.008) and coronary heart disease (OR 2.02. 95 % CI 1.18 - 3.47; p < 0.01). In conclusion, high fasting serum IGFBP-1 is related to increased five-year total and cardiovascular mortality in elderly men.     

Associations of C-Reactive Protein,Granulocytes and Granulocyte-to-Lymphocyte Ratio with Mortality from Breast Cancer in Non-Institutionalized American Women

Inflammation may play a role in breast cancer, but evidence in the general population is lacking. We investigated the association between serum inflammatory markers (C-reactive protein (CRP), absolute granulocyte count (AGC) and granulocyte-to-lymphocyte (G/L) ratio) and breast cancer (BCa) mortality in American women while accounting for adiposity. From the Third National Health and Nutrition Examination Survey (NHANES III) we selected all women aged 20+ without any known history of cancer (n = 7,780). Multivariable Cox regression models were used to assess CRP, AGC and G/L ratio in relation to mortality from BCa, all cancer, cardiovascular disease and all causes. Stratification analyses by body mass index (BMI) and waist circumference were performed to investigate the effect of adiposity on this association. During a mean follow-up of 167 months, 44 women died from BCa. After adjustments for BMI and waist circumference, only G/L ratio was associated to risk of BCa death (e.g. HR: 2.35, 95% CI: 1.36–4.06 for the 3^rd compared to the 1^st tertile, P_trend = 0.01). Except for a borderline interaction between CRP categories and obesity by BMI, no statistically significant interaction between markers and categories of BMI or waist circumference was observed. All three markers were associated with mortality from cardiovascular disease and all causes. Our findings support a role of inflammation in BCa mortality which may involve mechanisms apart from obesity, and potential usefulness of GLR as a marker in assessing inflammation and cancer.     

A Prospective Cohort Study Examining the Associations of Dietary Calcium Intake with All-Cause and Cardiovascular Mortality in Older Chinese Community-Dwelling People

Background

Most epidemiological studies of calcium intake and mortality risk have been conducted in populations with moderate to high calcium intake, and limited studies have focused on populations with low habitual calcium intake (i.e., mean dietary calcium intake <700 mg/d).

Objective

This study investigated the association between dietary calcium intake and death from all causes and cardiovascular disease in Chinese population with low habitual calcium intake.

Design

Data from 3,139 Chinese men and women in a population-based prospective cohort study, aged >=65 years and free of heart diseases or stroke at baseline, were analyzed. Primary outcome measures, identified from the death registry, were death from all causes and cardiovascular disease. Dietary calcium intake assessed using a validated food frequency questionnaire was categorized into sex-specific quartiles. Data on use of supplemental calcium (yes or no) including individual calcium supplements and other calcium containing supplement were collected. Cox regression models adjusted for demographic and lifestyle variables were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI).

Results

During a median of 9.1 years of follow-up, 529 all-cause deaths (344 men, 185 women) and 114 (74 men, 40 women) deaths from cardiovascular disease were identified. An inverse trend between dietary calcium intake and mortality was observed. Compared with the lowest quartile (<458 mg/d for men, <417 mg/d for women), the highest quartile of dietary calcium intake (>762 mg/d for men, >688 mg/d for women) had a significantly reduced risk of all-cause mortality (multivariate HR=0.63, 95% CI=0.49-0.81, P _trend<0.001) but an insignificant decreased risk of cardiovascular mortality (multivariate HR=0.70, 95% CI=0.41-1.21, P _trend=0.228). Similar inverse association was observed when the analyses were stratified on calcium supplemental use.

Conclusions

Higher intake of dietary calcium was associated with reduced risk of all-cause mortality and possibly cardiovascular mortality in Chinese older people with low habitual calcium intake.     

Leading Causes of Death among Asian American Subgroups (2003–2011)

Background

Our current understanding of Asian American mortality patterns has been distorted by the historical aggregation of diverse Asian subgroups on death certificates, masking important differences in the leading causes of death across subgroups. In this analysis, we aim to fill an important knowledge gap in Asian American health by reporting leading causes of mortality by disaggregated Asian American subgroups.

Methods and Findings

We examined national mortality records for the six largest Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) and non-Hispanic Whites (NHWs) from 2003-2011, and ranked the leading causes of death. We calculated all-cause and cause-specific age-adjusted rates, temporal trends with annual percent changes, and rate ratios by race/ethnicity and sex. Rankings revealed that as an aggregated group, cancer was the leading cause of death for Asian Americans. When disaggregated, there was notable heterogeneity. Among women, cancer was the leading cause of death for every group except Asian Indians. In men, cancer was the leading cause of death among Chinese, Korean, and Vietnamese men, while heart disease was the leading cause of death among Asian Indians, Filipino and Japanese men. The proportion of death due to heart disease for Asian Indian males was nearly double that of cancer (31% vs. 18%). Temporal trends showed increased mortality of cancer and diabetes in Asian Indians and Vietnamese; increased stroke mortality in Asian Indians; increased suicide mortality in Koreans; and increased mortality from Alzheimer’s disease for all racial/ethnic groups from 2003-2011. All-cause rate ratios revealed that overall mortality is lower in Asian Americans compared to NHWs.

Conclusions

Our findings show heterogeneity in the leading causes of death among Asian American subgroups. Additional research should focus on culturally competent and cost-effective approaches to prevent and treat specific diseases among these growing diverse populations.     

Effects of aerobic exercise on metabolic syndrome improvement in response to weight reduction

Objective: The objective was to test effects of aerobic exercise training on metabolic syndrome (MetSyn) improvement in response to weight reduction. Research Methods and Procedures: A total of 459 overweight and obese women (age, 49 ± 9 years; BMI, 28 ± 3 kg/m²) were recruited for a baseline examination to test the relationship between cardiorespiratory fitness and metabolic syndrome prevalence; among these, 67 subjects with MetSyn were treated with 14‐week weight‐loss programs, which included low‐calorie diet and aerobic exercise. The MetSyn was defined according to the Examination Committee of Criteria for “Metabolic Syndrome” in Japan. Maximal oxygen uptake (V?o _2max) during a maximal cycling test was measured as an index of cardiorespiratory fitness at baseline and after the intervention. Results: In the baseline examination, age‐ and BMI‐adjusted odds ratios for MetSyn prevalence in the low, middle, and upper thirds of V?o _2max were 1.0 (referent), 0.50 (95% confidence interval, 0.26 to 0.95), and 0.39 (95% confidence interval, 0.14 to 0.96), respectively (linear trend, p = 0.02). The adjusted odds ratios for MetSyn improvement in the two interventions with diet alone and diet plus exercise were 1.0 and 3.68 (95% confidence interval, 1.02 to 17.6; p = 0.04), respectively. Discussion: These results suggest that adding aerobic exercise training to a dietary weight‐reduction program further improves MetSyn (adjusted odds ratio, 3.68) in obese women, compared with diet alone. Further studies on an association between V?o _2max change and MetSyn improvement are needed.     

Long term effects of hysterectomy on mortality: nested cohort study

Objectives To investigate the long term risk (mean > 20 years) of death from all causes, cardiovascular disease, and cancer in women who had or had not had a hysterectomy.Design Nested cohort study.Setting Royal College of General Practitioners'' oral contraception study.Participants 7410 women (3705 flagged at the NHS central registries for cancer and death who had a hysterectomy during the oral contraception study and 3705 who were flagged but did not have the operation).Main outcome measures Mortality from all causes, cardiovascular disease, and cancer.Results 623 (8.4%) women had died by the end of follow-up (308 in the hysterectomy group and 315 in the non-hysterectomy group). Older women who had had a hysterectomy had a 6% reduced risk of death compared with women of a similar age who did not have the operation (adjusted hazard ratio 0.94, 95% confidence interval 0.75 to 1.18). Compared with young women who did not have a hysterectomy those who were younger at hysterectomy had an adjusted hazard ratio for all cause mortality of 0.82 (0.65 to 1.03). Hysterectomy was not associated with a significantly altered risk of mortality from cardiovascular disease or cancer regardless of age.Conclusion Hysterectomy did not increase the risk of death in the medium to long term.     

Body weight and mortality in middle aged British men: impact of smoking.

OBJECTIVE--To assess the relation between body mass index and mortality in middle aged British men. DESIGN--Men who were recruited for the British Regional Heart Study were followed up for a mean of nine years. SETTING--General practices in 24 British towns. SUBJECTS--7735 Men aged 40-59 years selected from the age-sex registers of one group practice in each of the 24 towns. MAIN OUTCOME MEASURE--Mortality from cardiovascular and non-cardiovascular causes. RESULTS--660 Of the men died. There was a U-shaped relation between body mass index and total mortality. Very lean men (less than 20 kg/m2) had by far the highest mortality followed by lean men (20-22 kg/m2) and obese men (greater than or equal to 28 kg/m2). The high mortality in lean and very lean men was due largely to non-cardiovascular causes, particularly lung cancer and respiratory disease, which are associated with cigarette smoking. In obese men deaths were more likely to be due to cardiovascular causes. There was a strong inverse association between body weight and cigarette smoking. When the pattern of mortality was examined by age, smoking habits, and pre-existing smoking related disease both very lean men and obese men consistently had an increased mortality. The U-shaped relation was most prominent in men in the oldest age group (55-59). Current smokers had a higher mortality than former smokers at virtually all values of body mass index. An increased mortality in lean men was seen only in current smokers and in men with smoking related disease. Among men who had never smoked, lean men had the lowest total mortality, thereafter mortality increased with increasing body mass index (p less than 0.01). CONCLUSIONS--This study provides strong evidence of the impact of cigarette smoking on body weight and mortality and strongly suggests that the benefits of giving up smoking are far greater than the problems associated with the increase in weight that may occur.     

Change in alcohol consumption and risk of death from all causes and from ischaemic heart disease.

OBJECTIVE--To examine the association between alcohol consumption and mortality from all causes and from ischaemic heart disease with a focus on differentiating between long term abstainers and more recent non-drinkers. DESIGN--Cohort study of changes in alcohol consumption from 1965 to 1974 and mortality from all causes and ischaemic heart disease during 1974-84. SETTING--Population based study of adult residents of Alameda County, California. SUBJECTS--2225 women and 1845 men aged 35 and over in 1965. MAIN OUTCOME MEASURES--Alcohol consumption in 1964 and 1974 and mortality from all causes and from ischaemic heart disease during 1974-84. RESULTS--There was a significantly higher risk of death from all causes and from ischaemic heart disease in women who gave up drinking between 1965 and 1974 than in women who continued to drink (relative risk 1.72, 95% confidence interval 1.11 to 2.66, and 2.75, 1.44 to 5.23, for all causes and ischaemic heart disease respectively). A significant increase in risk was not seen in men who gave up drinking (1.32, 0.87 to 2.01, and 0.95, 0.41 to 2.20, respectively). Among men, long term abstainers compared with drinkers were at increased risk of death from all causes and from ischaemic heart disease, though the associations were not significant (1.40, 0.98 to 2.00, and 1.40, 0.76 to 2.58, for all causes and ischaemic heart disease respectively). CONCLUSION--Some of the increased risk of death from all causes and from ischaemic heart disease associated with not drinking in women seems to be accounted for by higher risks among those who gave up drinking. Men who are long term abstainers may also be at an increased risk of death. The heterogeneity of the non-drinking group should be considered when comparisons are made with drinkers.     

Passive smoking and cardiorespiratory health in a general population in the west of Scotland.

OBJECTIVE-To assess the risk of cardiorespiratory symptoms and mortality in non-smokers who were passively exposed to environmental smoke. DESIGN--Prospective study of cohort from general population first screened between 1972 and 1976 and followed up for an average of 11.5 years, with linkage of data from participants in the same household. SETTING--Renfrew and Paisely, adjacent burghs in urban west Scotland. SUBJECTS--15,399 Men and women (80% of all those aged 45-64 resident in Renfrew or Paisley) comprised the original cohort; 7997 attended for multiphasic screening with a cohabitee. Passive smoking and control groups were defined on the basis of a lifelong non-smoking index case and whether the cohabitee had ever smoked or never smoked. MAIN OUTCOME MEASURE--Cardiorespiratory signs and symptoms and mortality. RESULTS--Each of the cardiorespiratory symptoms examined produced relative risks greater than 1.0 (though none were significant) for passive smokers compared with controls. Adjusted forced expiratory volume in one second was significantly lower in passive smokers than controls. All cause mortality was higher in passive smokers than controls (rate ratio 1.27 (95% confidence interval 0.95 to 1.70)), as were all causes of death related to smoking (rate ratio 1.30 (0.91 to 1.85] and mortality from lung cancer (rate ratio 2.41 (0.45 to 12.83)) and ischaemic heart disease (rate ratio 2.01 (1.21 to 3.35)). When passive smokers were divided into high and low exposure groups on the basis of the amount smoked by their cohabitees those highly exposed had higher rates of symptoms and death. CONCLUSION--Exposure to environmental tobacco smoke cannot be regarded as a safe involuntary habit.