Association of a diabetes risk score with risk of myocardial infarction,stroke, specific types of cancer,and mortality: a prospective study in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam cohort

To evaluate the impact of a recently developed, non-invasive risk score predictive for type 2 diabetes on the incidence and mortality of cardiovascular diseases and specific types of cancer. A total of 23,455 participants from the population-based European Prospective Investigation into Cancer and Nutrition (EPIC)–Potsdam study aged 35–65 years and free of diabetes and major chronic diseases at baseline (1994–1998) were followed through 2006 for incident myocardial infarction, stroke, types of cancer, and death. Risk score points were assigned to each participant based on age, waist circumference, height, physical activity, history of hypertension, smoking, alcohol consumption, and intake of red meat, whole-grain bread, and coffee. Hazard ratios (HRs) were estimated by Cox regression models. In age- and sex-adjusted analyses, participants with a high risk score (5-year probability to develop diabetes ≥ 10%) had significantly higher risks of myocardial infarction (HR 2.7, 95% CI 1.5–5.0) and stroke (1.9, 1.0–3.6), but not of colon, breast or prostate cancer incidence, than those with a low score (5-year probability < 1%). In addition, participants with a high risk score had considerably higher risks of cardiovascular (HR 4.6, 95% CI 2.3–9.4), cancer (1.7, 1.1–2.7), and total mortality (2.4, 1.8–3.4), the latter being equivalent to a difference in life expectancy of 13 years. These data indicate that a risk score predictive for type 2 diabetes is also related to elevated risks of myocardial infarction, stroke, and premature death in apparently healthy individuals and emphasize the need for early intervention in high-risk individuals.     

Modified Mediterranean diet and survival after myocardial infarction: the EPIC-Elderly study

Mediterranean diet is associated with lower incidence of coronary heart disease, and two randomised trials indicated that it improves prognosis of coronary patients. These trials, however, relied on a total of 100 deaths and evaluated designer diets in the clinical context. We have evaluated the association of adherence to the modified Mediterranean diet, in which unsaturates were substituted for monounsaturates, with survival among elderly with previous myocardial infarction within the European Prospective Investigation into Cancer and nutrition (EPIC) study. As of December 2003, after a median follow-up of 6.7 years, 2671 EPIC participants from nine countries were 60 years or older and had prevalent myocardial infarction but no stroke or cancer at enrolment, complete information on dietary intakes and important covariates and known survival status. Adherence to the modified Mediterranean diet was assessed through a 10-unit-scale. Mortality ratio in relation to modified Mediterranean diet was estimated through Cox regression controlling for possible confounding. Increased adherence to modified Mediterranean diet by two units was associated with 18% lower overall mortality rate (95% confidence interval 7–27%, fixed effects model). There was no significant heterogeneity by sex, age at enrolment, or country, although the association tended to be less evident among northern Europeans. Associations between food groups contributing to the modified Mediterranean diet and mortality were generally weak. A diet inspired by the Mediterranean pattern that can be easily adopted by Western populations is associated with substantial reduction of total mortality of coronary patients in the community.     

The Role of Diet,Alcohol, BMI,and Physical Activity in Cancer Mortality: Summary Findings of the EPIC Study

Evidence on the impact of diet, alcohol, body-mass index (BMI), and physical activity on mortality due to cancer and other cancer-related outcomes is still scarce. Herein, we reviewed the contribution of the European Prospective Investigation into Cancer and Nutrition (EPIC) study to the current state of the art on the role of these factors in cancer mortality. We identified 45 studies using a rapid systematic review methodology. Dietary factors associated with reduced cancer mortality included raw vegetable intake; dietary fiber intake; the Mediterranean diet; other dietary scores; other diet patterns including low meat eaters, vegetarians/vegans, or fish eaters; dietary intake (or biomarkers) of some vitamins (e.g., vitamin D, vitamin K2, or Vitamin C); and intake of lignans. Physical activity and following healthy lifestyle recommendations also reduced cancer mortality risk. In contrast, dietary factors associated with higher cancer mortality risk included poor diet quality, consumption of alcohol and soft drinks including juice, and, to a lesser extent, intake of some fatty acids. Excess weight and obesity also increased the risk of cancer mortality. The EPIC study holds valuable information on diet and lifestyle factors and offers a unique opportunity to identify key diet-related factors for cancer mortality prevention.     

Psychosocial factors as risk for coronary heart disease--status with special reference to the KORA platform

Psychosocial factors derived from concepts in health psychology and psychopathology are subject of extensive research to assess their power to predict a future coronary artery disease event in apparently healthy subjects. However, bio-behavioural factors have not been implemented in current guidelines of scoring schemes for calculating the risk of coronary events. The presented data were derived from the population-based MONICA Augsburg studies (S1-S3) conducted between 1984 and 1995. The psychosocial data set was available in approximately 13,000 subjects. The KORA follow-up study assessed the vital status for all participants (except for 56 persons) in 1998. Until then, 772 participants (531 men, 241 women) had died. The depressive symptomatology was derived from the von Zerrssen affective symptom check list combining 24 single symptom items with scores ranging from 0 to 3. Risks of total mortality and myocardial infarction were estimated from Cox proportional hazard ratio (HR) models adjusted for age and survey and multiple risk factors. Male participants with high scores in depression exhibited a significantly increased risk in total mortality (adjusted HR: 1.55; 95 % CI: 1.28 - 1.83, p < 0.0001) and for fatal and non-fatal coronary events (adjusted HR: 1.36; 95 % CI: 1.02 - 1.81, p < 0.035). Female participants reported higher values in depression scores; however, depression was not predictive for subsequent total mortality and fatal and non-fatal events in females. Depression in men yielded a significant interaction with obesity and increased levels of C-reactive protein (CRP). The inclusion of psychosocial factors, as demonstrated for depression, is likely to improve prediction of future adverse cardiovascular and total mortality. These factors may also play a crucial role in genotype-phenotype interaction.     

The Emerging Risk Factors Collaboration: analysis of individual data on lipid,inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value. Authors/collaborators in the Emerging Risk Factors Collaboration are listed at the end of this article.     

Mycotoxin Exposure and Renal Cell Carcinoma Risk: An Association Study in the EPIC European Cohort

Background: Mycotoxins have been suggested to contribute to a spectrum of adverse health effects in humans, including at low concentrations. The recognition of these food contaminants being carcinogenic, as co-occurring rather than as singularly present, has emerged from recent research. The aim of this study was to assess the potential associations of single and multiple mycotoxin exposures with renal cell carcinoma risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Methods: Food questionnaire data from the EPIC cohort were matched to mycotoxin food occurrence data compiled by the European Food Safety Authority (EFSA) from European Member States to assess long-term dietary mycotoxin exposures, and to associate these with the risk of renal cell carcinoma (RCC, n = 911 cases) in 450,112 EPIC participants. Potential confounding factors were taken into account. Analyses were conducted using Cox’s proportional hazards regression models to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs) with mycotoxin exposures expressed as µg/kg body weight/day. Results: Demographic characteristics differed between the RCC cases and non-cases for body mass index, age, alcohol intake at recruitment, and other dietary factors. In addition, the mycotoxin exposure distributions showed that a large proportion of the EPIC population was exposed to some of the main mycotoxins present in European foods such as deoxynivalenol (DON) and derivatives, fumonisins, Fusarium toxins, Alternaria toxins, and total mycotoxins. Nevertheless, no statistically significant associations were observed between the studied mycotoxins and mycotoxin groups, and the risk of RCC development. Conclusions: These results show an absence of statistically significant associations between long-term dietary mycotoxin exposures and RCC risk. However, these results need to be validated in other cohorts and preferably using repeated dietary exposure measurements. In addition, more occurrence data of, e.g., citrinin and fumonisins in different food commodities and countries in the EFSA database are a prerequisite to establish a greater degree of certainty.     

Sense of coherence and mortality in men and women in the EPIC-Norfolk United Kingdom prospective cohort study

This study tested the hypothesis that a personality disposition defined by a strong sense of coherence is associated with a reduced risk of mortality. The authors prospectively examined, for < or =6 years, the relation between a strong sense of coherence and mortality due to all causes, cardiovascular disease, and cancer among 20,579 participants aged 41-80 years from the European Prospective Investigation into Cancer (EPIC)-Norfolk Study in the United Kingdom. Data were collected in 1996-2002. Participants were recruited by post from general practice age-sex registers and subsequently completed a postal assessment of their sense of coherence. During follow-up, 1,024 deaths were recorded. A strong sense of coherence was associated with a 30% reduction in mortality from all causes (rate ratio=0.69, p<0.0001), cardiovascular disease (rate ratio=0.70, p=0.001), and cancer (rate ratio=0.74, p=0.003), independent of age, sex, and prevalent chronic disease. These associations were consistent by sex, except that no association was observed for cancer mortality in women. The association for all-cause mortality remained after adjustment for cigarette smoking history, social class, body mass index, systolic blood pressure, cholesterol, hostility, and neuroticism (rate ratio=0.76, p=0.002). Results suggest that a strong sense of coherence may confer some resilience to the risk of chronic disease.     

Dietary fibre and cardiovascular disease mortality in the UK Women’s Cohort Study

Dietary fibre has been associated with improvements in key risk factors for cardiovascular disease (CVD). Prior research has focussed more on CVD development in men and our aim was therefore to explore the association between dietary fibre intake and CVD mortality using data from the United Kingdom Women’s Cohort Study (UKWCS). Dietary fibre intake from 31,036 women was calculated both as non-starch polysaccharide (NSP) and using the Association of Official Analytical Chemist (AOAC) method from food-frequency questionnaires. Participants were free from history of CVD at baseline and mean age at recruitment was 51.8 years (standard deviation 9.2). Mortality records for participants were linked from national registry data and 258 fatal CVD cases [130 stroke, 128 coronary heart disease (CHD)] were observed over an average follow-up period of 14.3 years. Total dietary fibre (NSP/AOAC) and fibre from different food sources were not associated with fatal CHD, stroke or CVD risk in the full sample. For every 6 g/day increase in NSP, the hazard ratio (HR) was 0.91 (95 % confidence interval (CI) 0.76–1.08) or for every 11 g/day increase in fibre assessed as AOAC, the HR was 0.92 (95 % CI 0.80–1.05). Sensitivity analyses suggest a possible protective association for cereal sources of fibre on fatal stroke risk in overweight women, HR 0.80 (95 % CI 0.65–0.93) p < 0.01. In the UKWCS, a sample of health-conscious women, greater dietary fibre intake may confer no additional cardiovascular benefit, in terms of mortality, but may contribute to lower fatal stroke risk in some subgroups such as overweight women.     

Association of glycemic load with cardiovascular disease risk factors: The Women's Health Initiative Observational Study

ObjectiveAssociations between dietary glycemic load (GL) and cardiovascular disease risk factors, including plasma lipoprotein/lipid levels, blood pressure, and glucose metabolism factors, in the Women's Health Initiative Observational Study were examined.MethodsA random sample of 878 Observational Study participants (postmenopausal women 50–79 y of age) with baseline blood measurements (647 white, 104 black, 127 Hispanic) was included. Dietary GL was estimated from baseline food-frequency questionnaires, which assessed dietary intake over the previous 3 mo. At the baseline visit, participants completed demographic and health habit questionnaires, fasting blood samples were collected, anthropometric measurements were completed, and blood pressure was assessed.ResultsIn all participants combined, GL was inversely associated with high-density lipoprotein cholesterol (P for trend = 0.004) and positively associated with log₁₀-transformed triacylglycerols (P = 0.008). Although there were no statistically significant interactions of race/ethnicity with associations between GL and cardiovascular disease risk factors, stratified results were suggestive, showing that GL was positively associated with total cholesterol (P = 0.018) and low-density lipoprotein cholesterol (P = 0.038) in Hispanics. In white subjects, there was a trend of reduced high-density lipoprotein cholesterol with higher GL (P = 0.003), whereas GL was positively associated with log₁₀-transformed triacylglycerols (P = 0.015). Associations between GL and high-density lipoprotein cholesterol and between GL and triacylglycerols also differed by body mass index, although the interactions were not statistically significant.ConclusionAmong these generally healthy postmenopausal women, GL was associated with high-density lipoprotein cholesterol and triacylglycerols. Suggestive effects of race/ethnicity and body mass index on these associations need to be confirmed in larger studies.     

Diabetes mellitus, coronary heart disease incidence, and death from all causes in African American and European American women: The NHANES I epidemiologic follow-up study

Few data are available on risk for coronary heart disease in African American women with diabetes mellitus, a well-established coronary risk factor in European American women. This study tests the hypothesis that medical history of diabetes predicts coronary heart disease incidence in African American women in a national cohort. Participants in the NHANES I Epidemiologic Follow-up Study in this analysis were 1035 African American and 5732 European American women aged 25-74 years without a history of coronary heart disease. Average follow-up for survivors was 19 years (maximum 22 years). Risk of incident coronary heart disease by baseline diabetes status was estimated. Proportional hazards analyses for African American women aged 25-74 revealed significant associations of coronary heart disease risk with diabetes after adjusting for age (RR = 2.40; 95% CI, 1.58-3.64, P < 0.01). After adjusting for age, smoking, and low education, there was an elevated risk in diabetics age 25-74 (RR = 2. 34; 95% CI, 1.54-3.56, P < 0.01); this association did not differ significantly from that for European American women. Excess coronary incidence in African American compared to European American women aged 25-64 was statistically explained by controlling for diabetes history, age, education, and smoking but only partly explained by age and diabetes history. In African American women aged 25-74, diabetes was also associated with increased coronary heart disease, cardiovascular, and all-cause mortality. The population attributable risk of coronary heart disease incidence associated with a medical history of diabetes was 8.7% in African American women and 6.1% in European American women. Medical history of diabetes was a significant predictor of coronary heart disease incidence and mortality in African American women and explained some of the excess coronary incidence in younger African American compared to European American women.     

Association of Adherence to the Mediterranean Diet with All-Cause Mortality in Subjects with Heart Failure

We investigated the associations of adherence to the Mediterranean diet with all-cause and cardiovascular mortality in patients with heart failure. We analyzed the National Health and Nutrition Examination Survey (NHANES) participants from 1999 to 2010, with their vital status confirmed through to the end of 2011. The alternate Mediterranean Diet Index (aMED) was used to assess study participants’ adherence to the Mediterranean diet according to information on dietary questionnaires. We conducted weighted Cox proportional hazards regression models to determine the associations of adherence to the Mediterranean diet (aMED ≥ median vs. <median) with all-cause and cardiovascular mortality in participants with a history of heart failure. A total of 832 participants were analyzed, and the median aMED was 3. After a median follow-up of 4.7 years, 319 participants had died. aMED ≥ 3 (vs. <3) was not associated with a lower risk of all-cause (adjusted HR 0.797, 95% CI 0.599–1.059, p = 0.116) and cardiovascular (adjusted HR 0.911, 95% CI 0.539–1.538, p = 0.724) mortality. The findings were consistent across several subgroup populations. Among the components of aMED, a lower intake of red/processed meat was associated with a higher risk of mortality (adjusted HR 1.406, 95% CI 1.011–1.955, p = 0.043). We concluded that adherence to the Mediterranean diet was not associated with a lower risk of all-cause and cardiovascular mortality in participants with a history of heart failure. The higher risk of mortality associated with a lower intake of red/processed meat deserves further investigation.     

Childhood socioeconomic status and risk of cardiovascular disease in middle aged US women: a prospective study.

OBJECTIVE--To examine prospectively the relationship of childhood socioeconomic status and risk of cardiovascular disease in middle aged women. DESIGN--A prospective cohort of women with 14 years follow up data (1976-90). SUBJECTS--A total of 117,006 registered female nurses aged 30 to 55 years in 1976 and free of diagnosed coronary heart disease, stroke, and cancer at baseline. MAIN OUTCOME MEASURES--Incident fatal coronary heart disease, non-fatal myocardial infarction, and stroke (fatal and non-fatal). RESULTS--Low socioeconomic status in childhood was associated with a modestly increased risk of incident non-fatal myocardial infarction and total cardiovascular disease in adulthood. Compared with middle aged women from white collar childhood backgrounds, the age adjusted risk of total cardiovascular disease for women from blue collar backgrounds was 1.13 (95% CI 1.02, 1.24) and that of non-fatal myocardial infarction was 1.23 (95% CI 1.06, 1.42). No significant increase in risk was observed for stroke or fatal coronary heart disease. Adjustment for differences in family and personal past medical history, medication use, exercise, alcohol intake, diet, birth weight, being breastfed in infancy, and adult socioeconomic circumstance somewhat attenuated the increased risks observed for women from blue collar childhood socioeconomic backgrounds. In multivariate analysis, women whose fathers had been manual labourers had the highest relative risk of total coronary heart disease (RR = 1.53; 95% CI 1.09, 2.16) and non-fatal myocardial infarction (RR = 1.67; 95% CI 1.11, 2.53) when compared with women whose fathers had been employed in the professions. CONCLUSION--In this group lower childhood socioeconomic status was associated with a small but significant increase in the risk of total coronary heart disease as well as non-fatal myocardial infarction. For women from the most socioeconomically disadvantaged childhood backgrounds, the association is not explained by differences in a large number of cardiovascular risk factors, by differences in adult socioeconomic status, or by differences in indices of nutrition during gestation or infancy.     

Smoking predicts long-term mortality in stroke: The European Prospective Investigation into Cancer (EPIC)-Norfolk prospective population study

BACKGROUND.: While the relationship between risk factors and stroke is well established, there is less information about the risk factors and survival after stroke. We examined the independent association between cardiovascular and modifiable lifestyle risk factors and subsequent mortality in people with stroke. METHODS.: 308 free-living men and women with stroke at baseline survey in 1993-1997 participating in the European Prospective Investigation into Cancer (EPIC)-Norfolk were followed up for long-term mortality (average follow-up 7.5 years). Using Cox's proportional hazards model, we assessed the relationships between an individual's age, sex, cardiovascular risk profile including systolic blood pressure, body mass index, cholesterol, history of diabetes and lifestyle behaviors smoking and alcohol consumption and subsequent mortality up to July 2004. RESULTS.: There were a total of 100 deaths during follow-up (total person years = 2318). Advancing age (RR 1.72, 95%CI: 1.42, 2.09) and current smoking (RR 2.27, 95%CI: 1.12, 4.57) predicted higher risk while female sex was associated with reduced risk (RR 0.51, 95%CI; 0.31, 0.84) of subsequent mortality after stroke independently of other risk factors investigated. CONCLUSIONS.: Our findings may provide further empirical encouragement for smoking cessation after stroke.     

Dietary indices,cardiovascular risk factors and mortality in middle-aged adults: findings from the Aerobics Center Longitudinal Study

PurposeWe examined the association between three predefined dietary indices and both cardiovascular disease (CVD) risk factors and long-term mortality in adult Aerobics Center Longitudinal Study’s participants.MethodsBetween 1987 and 1999, 12,449 (77% male) participants aged 20–84 years completed a clinical examination, which included dietary assessment by 3-day diet records. Three dietary indices were calculated: the Ideal Diet Index, the Diet Quality Index, and the Mediterranean Diet Score. CVD risk factors measurements included body mass index, total cholesterol, fasting glucose, blood pressure, and cardiorespiratory fitness. We calculated hazard ratios from Cox regression analyses, adjusting for potential confounders including physical fitness.ResultsHigher Ideal Diet Index, Diet Quality Index, and Mediterranean Diet Score scores were consistently associated with lower body mass index, cholesterol and glucose levels, and diastolic blood pressure, and higher cardiorespiratory fitness (all P < .05). However, after adjusting for age, sex, energy intake, and baseline examination year, the indices were not significantly related to all-cause, CVD, or cancer mortality. No association was observed in fully adjusted models, which controlled for fitness.ConclusionsAlthough these dietary indices based on 3-day diet records are strongly associated cross-sectionally to CVD risk profile of middle-aged men and women, they do not add to ability to predict long-term mortality in follow-up.     

Vitamin C intake and risk of ischemic heart disease in a population with a high prevalence of smoking

OBJECTIVE: Epidemiological data on the relationship between vitamin C intake and ischemic heart disease (IHD) risk are limited in the Asian population, with a high prevalence of smoking. This study aims to investigate the association between vitamin C intake and the incidence of non-fatal IHD in Korean men. METHODS: The case group consisted of 108 patients with electrocardiogram-confirmed myocardial infarction or angiographically confirmed (>or=50% stenosis) coronary artery disease (CAD) who were admitted to a university teaching hospital in Seoul, Korea. The controls were 142 age-matched patients admitted to the departments of ophthalmology and orthopedic surgery at the same hospital. Vitamin C intake was assessed by a nutritionist using a semi-quantitative food frequency method, and body mass index (BMI), tobacco use and past history of cardiovascular disease were determined by examination and interview. RESULTS: After controlling for cardiovascular risk factors, including BMI, smoking, past history of hypertension, past history of hyperlipidemia, dietary intakes of energy, total fat (or subtype of fat), cholesterol, beta-carotene, and vitamin E, the odds ratio (OR) of non-fatal IHD was 0.34 (95% confidence interval (CI) 0.13-0.90) in the highest tertile of vitamin C intake compared with those in the lowest tertile. In a subgroup analysis, which compared nonsmokers in the highest tertile of vitamin C intake to current smokers in the lowest tertile of vitamin C intake, the odds ratio of developing non-fatal IHD was 0.12 (95% CI 0.02-0.77). CONCLUSION: This study suggests that higher intake of vitamin C is associated with the decreased risk of non-fatal IHD in a population with a high prevalence of smoking.     

Leisure time physical activity and long-term cardiovascular and cancer outcomes: the Busselton Health Study

The study aimed to investigate whether meeting leisure time physical activity recommendations was associated with reduced incident and fatal cancer or cardiovascular disease (CVD) in a community-based cohort of middle- to late-aged adults with long-term follow-up. At baseline, 2,320 individuals were assessed on a large number of lifestyle and clinical parameters including their level of physical activity per week, other risk factors (e.g. smoking and alcohol use) various anthropometric measures, blood tests and medical history. Individuals were linked to hospital and mortality registry data to identify future cancer and cardiovascular events (fatal and non-fatal) out to 15 years of follow-up. Cox regression analyses adjusted for relevant confounders identified a priori were used to estimate risk for all-cause, cancer-specific and CVD-specific mortality. In the full cohort an estimated 21 % decreased risk for all-cause mortality (HR 0.79; 95 % CI 0.66–0.96) and 22 % decreased risk for fatal/non-fatal CVD events (HR 0.78; 95 % CI 0.66–0.92) was associated with baseline self-reported physical activity levels of 150 min or more. After exclusion of those with chronic co-morbidities (CVD, cancer, diabetes, chronic obstructive pulmonary disease, hypertension treatment) at baseline, lower risk for fatal/non-fatal CVD events remained significantly associated with 150 min or more of physical activity (HR 0.77; 95 % CI 0.62–0.96). Results from this well established prospective community-based cohort study support the role of leisure time physical activity in reducing all-cause mortality and CVD events (fatal/nonfatal) in the broader population studied. The data also suggest that physical activity associated reductions in risk for CVD events (fatal/nonfatal) were not overly impacted by prevalent key non-communicable diseases.     

The long-term effect of dietary advice in men with coronary disease: follow-up of the Diet and Reinfarction trial (DART)

OBJECTIVE: To assess the long-term effect of dietary advice on diet and mortality after a randomised trial of men with a recent history of myocardial infarction. DESIGN: Questionnaire survey and mortality follow-up after a trial of dietary advice. SETTING: Twenty-one hospitals in south Wales and south-west England. SUBJECTS: Former participants in the Diet and Reinfarction Trial. MAIN OUTCOME MEASURES: Current fish intake and cereal fibre intake. All-cause mortality, stroke mortality and coronary mortality. RESULTS: By February 2000, after 21147 person years of follow-up, 1083 (53%) of the men had died. Completed questionnaires were obtained from 879 (85%) of the 1030 men alive at the beginning of 1999. Relative increases in fish and fibre intake were still present at 10 y but were much smaller. The early reduction in all-cause mortality observed in those given fish advice (unadjusted hazard 0.70 (95% CI 0.54, 0.92)) was followed by an increased risk over the next 3 y (unadjusted hazard 1.31 (95% CI 1.01, 1.70). Fat and fibre advice had no clear effect on coronary or all-cause mortality. The risk of stroke death was increased in the fat advice group-the overall unadjusted hazard was 2.03 (95% CI 1.14, 3.63). CONCLUSIONS: In this follow-up of a trial of intensive dietary advice following myocardial infarction we did not observe any substantial long-term survival benefit. Further trials of fish and fibre advice are feasible and necessary to clarify the role of these foods in coronary disease.     

High cardiovascular mortality in Russia cannot be explained by the classical risk factors. The Arkhangelsk study 2000

Since the beginning of the 1990s the public health situation in Russia has been characterized by an extremely high mortality and a significant reduction in life expectancy. Cardiovascular diseases remained the major cause of death. Only a few large population studies were conducted in Russia during this period. A total of 1968 men and 1737 women aged 18–75 years participated in a health survey in Arkhangelsk, Russia, over the period 1999–2000. Investigation included assessment of classic cardiovascular risk factors (family history, smoking, blood pressure, and blood lipids) along with general health variables. The paper presents sex specific data on risk factors for coronary heart disease. Though the cardiovascular mortality is high in Russia, the calculated risk for coronary heart disease (the Framingham risk score and the Norwegian risk score) was lower in all age groups of men and women in Arkhangelsk compared with studies from the Western Europe and USA. Our data suggest that high cardiovascular mortality in Russia may be driven not only by the classic risk factors for coronary heart disease.     

Progetto ATENA,A study on the etiology of major chronic diseases in women: Design,rationale and objectives

In spite of their important impact on populations, a number of diseases - all types of cancer and coronary heart disease in women - are rare events for statistical analysis and often analyzed in designs affected by selection and information biases, such as case-control studies. Large cohort studies based on the storage of biological specimens appear to be the most suitable solution for identifying risks for those diseases.Progetto ATENA, a study on the etiology of major chronic diseases in women is based on this design. Ten thousand women, aged 30–69 years, living in the area of the city of Naples, free of cancer and cardiovascular disease, are being recruited over a four-year period. Ten per cent of the cohort is being randomly selected from the electoral roles, the rest will be volunteers.Information on dietary habits, reproductive history, familiarity for chronic disease, active smoking habits and passive smoking exposure, physical activity, and socio-demographic data are being collected. Clinical data such as blood pressure, anthropometry, and electrocardiogram are also taken. All the participants provide biological samples of blood (fasting drawing) and urine (timed morning spot). The biological samples are processed in order to explore the main areas under study (nutritional markers, metabolism, endocrinology, genetics, environmental exposure markers, thrombogenesis). The samples are stored in liquid nitrogen (–196° C) as soon as the blood and urine processing have been finished. An appropriate follow-up information system on the health status of the participants is being set up to estimate incidence and mortality rates.Corresponding author.     

Prospective associations between sustainable dietary pattern assessed with the Sustainable Diet Index (SDI) and risk of cancer and cardiovascular diseases in the French NutriNet-Santé cohort

To ensure a sustainable development, it is essential to better characterize the relationships between diet sustainability and health. We investigated the associations between sustainable dietary patterns, assessed using the Sustainable Diet Index (SDI) and the risk of cancer and cardiovascular diseases in a large prospective cohort of French volunteers. We computed the SDI among 25,592 participants of the NutriNet-Santé cohort using a database developed within the BioNutriNet project comprising nutritional, behavioral, environmental and economic data. Health status of each participant was collected from 2014 to 2018 and validated by physicians. Associations between the SDI and risk of chronic diseases (cancer and cardiovascular diseases) were assessed using multivariable Cox models. 640 incident chronic diseases occurred during the 3.8-year follow-up (483 cancer cases and 158 cardiovascular disease cases). A higher SDI was associated with a lower risk of overall chronic diseases after adjustment for potential confounding factors. Participants in the fourth quartile, reflecting the highest sustainable dietary patterns, exhibited a significant decrease in risk of cancers or cardiovascular diseases (HRQ4 vs. Q1 = 0.61 (95% CI 0.47–0.80), P-trend = 0.0002). More specifically, this association was observed for cancers in the fully adjusted model but was not statistically significant for cardiovascular diseases. Although these results need to be confirmed by other observational studies, they support the fact that a wide adoption of sustainable dietary patterns may contribute to improving global health in France and argue for existing dietary patterns exhibiting cobenefits for human health and the environment.