Racial differences and hypertension.
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Africa↗
Biomedical subjects
M G Marmot
Publications and source records attributed to M G Marmot.
Alcohol and blood pressure: the INTERSALT study.
OBJECTIVES: To assess the relation between alcohol intake and blood pressure in men and women and in men at younger and older ages; to examine the influence of amount and pattern of alcohol consumption, as well as of acute effects, taking into account body mass index, smoking, and urinary sodium and potassium excretion. DESIGN: Subjects reported alcohol consumption for each of seven days before standardised blood pressure measurement, and whether they had consumed any alcohol in the 24 hours before measurement. SETTING: 50 centres worldwide. SUBJECTS: 4844 men and 4837 women aged 20-59. MAIN OUTCOME MEASURES: Effect of alcohol on blood pressure estimated by taking a weighted average of regression coefficients from centres. Acute effect assessed by examining mean differences in blood pressure of non-drinkers and of heavy drinkers who had and had not consumed alcohol in the 24 hours before measurement. Effect of pattern of consumption assessed by examining mean differences in blood pressure of non-drinkers compared with drinkers (i) whose intake was concentrated in fewer days or who were drinking more frequently, and (ii) whose alcohol intake varied little over the seven days or varied more substantially, as indicated by the standard deviation of daily consumption. RESULTS: Of the 48 centres in which some people reported consuming at least 300 ml/week of alcohol, 35 had positive regression coefficients linking heavy alcohol consumption to blood pressure. Overall, alcohol consumption was associated with blood pressure, significantly at the highest intake. After account was taken of key confounders, men who drank 300-499 ml alcohol/week had systolic/diastolic blood pressure on average 2.7/1.6 mmHg higher than non-drinkers, and men who drank > or = 500 ml alcohol/week had pressures of 4.6/3.0 mmHg higher. For women, heavy drinkers (> or = 300 ml/week) had blood pressures higher by 3.9/3.1 mmHg than non-drinkers. Heavy drinking and blood pressure were strongly associated in both sexes, and in men at both younger (20-39 years) and older (40-59 years) ages. In men who were heavy drinkers, episodic drinkers (those with great variation in daily alcohol consumption) had greater differences in blood pressure compared with non-drinkers than did regular drinkers of relatively constant amounts. CONCLUSION: The significant relation of heavy drinking (3-4 or more drinks/day) to blood pressure, observed in both men and women, and in younger and older men, was independent of and added to the effect on blood pressure of body mass index and urinary excretion of sodium and potassium. The findings indicate the usefulness of targeting those at high risk as well as the general population to reduce the adverse effects of alcohol on blood pressure.
Adult↗
Relationship of glucose intolerance to coronary risk in Afro-Caribbeans compared with Europeans.
Afro-Caribbeans have low mortality rates from coronary heart disease, despite a high prevalence of diabetes mellitus. We examined 1166 Afro-Caribbean and European men and women aged 40-64 years in a community survey in London, UK. Prevalence of glucose intolerance (combining impaired glucose tolerance, new and known diabetes) was 31% in Afro-Caribbeans and 14% in Europeans (p < 0.001). In men, the prevalence of probable coronary heart disease was 6% in Afro-Caribbeans and 13% in Europeans (p < 0.01). Triglyceride was lower in Afro-Caribbeans than Europeans; in men, HDL cholesterol was higher. Afro-Caribbean men were less centrally obese, while Afro-Caribbean women were more centrally obese than their European counterparts. Fasting and 2-h insulin levels were higher in Afro-Caribbeans than Europeans. Glucose intolerance was associated with high triglyceride, low HDL cholesterol and central obesity in European but not in Afro-Caribbean men. In Europeans, fasting triglyceride was 1.49 mmol/l in normoglycaemic and 1.89 mmol/l in glucose intolerant men (p < 0.05), in Afro-Caribbean men triglyceride was 1.08 and 1.22 mmol/l, respectively. Waist hip ratio was 0.94 in normoglycaemic, and 0.98 in glucose intolerant European men (p < 0.001). In Afro-Caribbean men, waist hip ratio was 0.93 in both groups. At each level of insulin, glucose or central obesity, triglyceride was lower in Afro-Caribbean men and women than in Europeans. We speculate that despite high insulin levels, Afro-Caribbeans have a favourable lipoprotein pattern which persists in the presence of glucose intolerance, and may be related to body fat distribution.(ABSTRACT TRUNCATED AT 250 WORDS)
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The assessment of biological age: a report from the Department of Environment Study.
Indicators of ageing were measured in 397 male and 130 female London Civil Servants aged from 37 to 58 years of age. Grey hair, skin inelasticity, and arcus senilis were strongly and independently related to chronological age. Also independently related were serum albumin (negatively related in both sexes), baldness, serum creatinine, systolic blood pressure, serum calcium (negatively) and ESR in men, and serum cholesterol in women. Chronological age was regressed on the above variables for men and women separately to provide regression equations. Biological age for an individual was calculated by entering his or her results and calculating the residuals. Biological age in those who stopped smoking tended to be younger than chronological age by an average of 12-13 months in men and 1-4 months in women. Men and women who had never smoked had higher biological than actual ages but not after adjusting for regression dilution bias. Men who currently smoked had higher biological ages of 2-3 months but not women smokers (4-6 months lower). Similarly, men of lower employment grades had an average biological age 13 months older and women 8 months, compared with higher employment grades. These differences between employment grade appeared to be due to ESR, arcus senilis, systolic blood pressure and serum cholesterol. These four measurements may be markers of biological rather than chronological age, and the value of attempting to measure biological age is discussed.
Adult↗
Age differences in biochemical and hematological measures during middle age.
Biochemical and hematological measures possibly associated with ageing were measured on a single occasion in 3402 male and 2152 female London Civil Servants aged from 35 to 59 years of age. These included erythrocyte sedimentation rate (ESR), blood hemoglobin and serum albumin, calcium, bilirubin, creatinine, urea, urate, high density lipoprotein (HDL), and total cholesterol. Independently and positively related to age were ESR with an estimated 47% 'increase' in men over the 15 years between ages 40 to 55 and a 40% increase in women; serum urea had a 6%/15-year increase in men and 20% in women; total cholesterol had a 6%/15-year increase in men and 18% in women; serum creatinine 'increased' by 2%/15-years in men and 5% in women. In women, urate, HDL cholesterol and hemoglobin increased with age group. Negatively related to age was serum bilirubin in both sexes (8% and 6% 'fall'/15-years in men and women respectively). Serum albumin and calcium fell with age group in men. The sexes differed in their relationship to aging for total cholesterol and HDL cholesterol (greater increase in women), serum calcium (small decrease in men and small increase in women), urate and hemoglobin (increases in women but not men). Urea increased more in women than men, and albumin decreased more in men than women (p < 0.001 for all comparisons with the exception of HDL cholesterol, p < 0.01). Changes during the menopause were thought to explain some of these findings.
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Relationship of hyperinsulinemia to dietary intake in south Asian and European men.
In South Asians (Indians, Pakistanis, and Bangladeshis) settled overseas, high rates of coronary disease and non-insulin-dependent diabetes occur in association with central obesity and insulin resistance. To examine whether these disturbances were related to diet, we measured 7-d weighed intakes in 173 South Asian and European men aged 40-69 y in London. In South Asians compared with Europeans, respectively, mean energy intake was lower (9.5 vs 10.8 MJ/day, P < 0.001), total fat intake was lower (36.5% vs 39.2% of energy intake, P = 0.007), starch intake was higher (28.0% vs 21.5% of energy, P < 0.001), polyunsaturated fatty acid intake was higher (8.2% vs 7.0% of energy, P = 0.02), and dietary fiber intake was higher (3.2 vs 2.0 g/MJ, P < 0.001). Elevated serum insulin concentrations at 2 h postglucose were associated positively with carbohydrate intake (P = 0.001) and inversely with alcohol intake (P = 0.006), but not with saturated fatty acid intake. The high coronary risk in South Asian people is not explained by any unfavorable characteristic of South Asian diets.
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What determines mortality risk in male former cigarette smokers?
OBJECTIVES: The purpose of this study was to examine what factors determine the mortality experience of male ex-cigarette smokers, those who no longer smoke at all and those who changed to pipe or cigar smoking. METHODS: A cohort study was undertaken with 18-year mortality data on 19,018 men. RESULTS: Ex-cigarette smokers had an intermediate mortality risk compared with never and current smokers. Ex-cigarette smokers who switched to pipe smoking had higher mortality than those who no longer smoked at all. The mortality rates for pipe and cigar smokers who were former cigarette smokers were higher than those for pipe or cigar smokers who had never smoked cigarettes. Ex-cigarette smokers who consumed more than 20 cigarettes per day for more than 20 years experienced increased mortality for both coronary heart disease and neoplasms, even after 30 years of cessation. CONCLUSIONS: These results support the notion that an elevated mortality risk may be seen for ex-cigarette smokers, even after they have given up smoking for many years. Ex-cigarette smokers who change to a pipe have a greater mortality risk than those who no longer smoke at all.
Adult↗
Psycho-emotional stress and salt intake may interact to raise blood pressure.
AIM: This study examined whether work-related aspects of stress, alone or in association with a high salt intake, are associated with a raised blood pressure. METHODS: A total of 384 male civil servants (35-51 years) collected a 24h urine sample and were interviewed using measures of work-related stress. Their blood pressure was taken at a civil-service medical clinic and was self-measured at home. RESULTS: Systolic/diastolic pressure averaged ( +/- SD ) 135 +/- 19/84 +/- 14 mmHg at the clinic and 123 +/- 16/80 +/- 11 mmHG on self-measurements at home. The 24h urinary sodium excretion was 172 +/- 65 mmol. The overall stress score was categorized as low in 98 men, medium in 193 men and high in 93 men. Stress itself was not associated with an elevated pressure. However, in multivariate analyses with adjustments for age and body mass index, a stress-sodium interaction in the determination of the clinic systolic (P = 0.05) and diastolic (P = 0.08) pressure became apparent. At a sodium excretion of 100 mmol/24h (10th percentile), increasing stress from low to high was associated with a fall in pressure, averaging 4.5 mmHg for systolic pressure and 1.4 mmHg for diastolic pressure. By contrast, at 250 mmol/24h (90th percentile) the same stress increase was associated with a rise in pressure of 6.3 mmHg systolic and 5.9 mmHg diastolic. CONCLUSION: The present study suggests that sodium intake and work-related stress may interact to determine blood pressure. This interaction is probably dynamic in nature, so that the contribution of each factor to blood pressure can only be determined if both are measured.
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Social deprivation and premature mortality: regional comparison across England.
OBJECTIVE: To investigate the pattern and size of the relationship between social deprivation in electoral wards and premature mortality for each health region in England. DESIGN: Ecological study using 1981 census variables and data on mortality for 1981-5. SETTING: 14 regional health authorities in England. MAIN OUTCOME MEASURE: Mortality under the age of 65 years from all causes, coronary heart disease, and smoking related diseases in men and women. RESULTS: Increasing deprivation was significantly associated with mortality from all causes, coronary heart disease, and smoking related diseases. The relationship was linear with no apparent threshold. Correlation coefficients were generally greater for deaths from all causes and smoking related diseases and for men compared with women. The slope of the relationship between deprivation and mortality varied among regions. Variations in mortality still existed between regions for equal levels of deprivation. CONCLUSION: Deprivation of an area and premature mortality are strongly linked. The effects of deprivation can be seen throughout the range of affluence and are not limited to the poorest areas. Current targets for reducing coronary heart disease mortality may be achievable if the mortality in poor areas can be reduced to the rates in affluent areas.
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Explaining socioeconomic differences in sickness absence: the Whitehall II Study.
OBJECTIVE: To describe and explain the socioeconomic gradient in sickness absence. DESIGN: Analysis of questionnaire and sickness absence data collected from the first phase of the Whitehall II study. Grade of employment was used as a measure of socioeconomic status. SETTING: 20 civil service departments in London. SUBJECTS: 6900 male and 3414 female civil servants aged 35-55 years. MAIN OUTCOME MEASURES: Rates of short spells (< or = 7 days) and long spells (> 7 days) of sickness absence. RESULTS: A strong inverse relation between grade of employment and sickness absence was evident. Men in the lowest grade had rates of short and long spells of absence 6.1 (95% confidence interval 5.3 to 6.9) and 6.1 (4.8 to 7.9) times higher than those in the highest grade. For women the corresponding rate ratios were 3.0 (2.3 to 3.9) and 4.2 (2.5 to 6.8) respectively. Several risk factors were identified, including health related behaviours (smoking and frequent alcohol consumption), work characteristics (low levels of control, variety and use of skills, work pace, and support at work), low levels of job satisfaction, and adverse social circumstances outside work (financial difficulties and negative support). These risk factors accounted for about one third of the grade differences in sickness absence. CONCLUSION: Large grade differences in sickness absence parallel socioeconomic differences in morbidity and mortality found in other studies. Identified risk factors accounted for a small proportion of the grade differences in sickness absence. More accurate measurement of the risk factors may explain some of the remaining differences in sickness absence but other factors, as yet unrecognised, are likely to be important.
Absenteeism↗
Gender and employment grade differences in blood cholesterol, apolipoproteins and haemostatic factors in the Whitehall II study.
In the first Whitehall study, plasma cholesterol was a strong predictor of coronary heart disease (CHD) but it showed a positive association with grade of employment: the higher the grade the higher the level. Because it could not explain the higher rate of CHD in lower employment grades, further investigation of biochemical CHD risk factors has been conducted with data from the baseline examination of the Whitehall II cohort in 1985-88. These data also allow investigation of gender differences and the effect of menopause. Serum cholesterol (6860 men and 3374 women) and apolipoproteins A-I and B (apo AI and apo B) were measured in those aged 35-55 working in the London offices of twenty Civil Service departments. Plasma fibrinogen and factor VII were determined in 45-55 year olds. The apo B/apo AI ratio (95% confidence interval) after age adjustment is lowest in premenopausal women: 0.557 (0.549-0.565), intermediate in postmenopausal women: 0.601 (0.589-0.613) and highest in men: 0.703 (0.698-0.709). After age adjustment fibrinogen is higher in postmenopausal (2.90 (2.85-2.95) g/l) than in premenopausal women (2.78 (2.71-2.84) g/l), who have higher levels than men (2.64 (2.62-2.67) g/l). A positive association with employment grade is seen for apo AI and a negative association is seen for fibrinogen, apo B (women only) and the apo B/apo AI ratio, after age adjustment. These patterns are consistent with the higher rates of CHD in lower grades. Cholesterol and factor VII show no gradient with our sensitive measure of social position. After adjusting for the effects of smoking rates, alcohol consumption, exercise and dietary pattern, as well as age, ethnicity, body mass index and report of symptoms, the regression coefficient for apo AI on employment grade is reduced by 43% in men and 70% in women. Corresponding reductions for fibrinogen are 53% and 65%. These attenuations suggest that a considerable part of the social gradients in apo AI and fibrinogen are explained by variations in health related behaviours. The remaining gradients may represent effects independent of these behaviours.
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Changes in total serum cholesterol and other risk factors for cardiovascular disease in Japan 1980-1989.
To monitor recent changes in Japan in diet and risk factors for cardiovascular disease (CVD), in the light of the decline on coronary heart disease, total serum cholesterol levels and other risk factors were compared between two nationwide health surveys in 1980 and 1989 conducted in the same population as the annual National Nutrition Surveys. Between 1980 and 1989, age-adjusted total serum cholesterol levels increased from 4.84 to 5.22 for men and from 4.91 to 5.24 mmol/l for women. Prevalence of age-adjusted hypercholesterolaemia of > or = 5.68 mmol/l (220 mg/dl) increased from 15.8% to 29.4% for men and from 18.4% to 30.6% for women. Decline in blood pressure was observed for both sexes. Prevalence of smoking decreased from 64.7% to 58.7% in men while prevalence in women remained low (from 10.1 to 9.9%). Considerable increases in total serum cholesterol levels do not offer an explanation of the recent decline in mortality from coronary heart disease in Japan. This may, in part, be related to a decline in blood pressure levels.
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Alcohol consumption and sickness absence: from the Whitehall II study.
Previous studies suggest that problem drinkers have markedly increased sickness absence. However, it is not clear how more moderate alcohol consumption and abstinence relate to sickness absence. As part of the Whitehall II study the relationship between different drinking patterns and sickness absence is examined. A total of 10,314 male and female civil servants completed a baseline questionnaire about their drinking habits--the amount of alcohol consumed over the past 7 days and the frequency of drinking over the past 12 months. All sickness absence has been recorded prospectively. Drinking patterns and sickness absence are examined for short spells (< or = 7 days) and long spells (> 7 days) adjusting for other causes of sickness absence: age, grade of employment, smoking, work characteristics and baseline health. Alcohol consumption was strongly related to employment grade, the lower the grade the higher proportion of men and women reporting no alcohol consumption. For men the relation of alcohol intake to short spells of sickness absence (< or = 7 days) appeared to be U-shaped, for long spells (> 7 days) increased rates of absence were found only in frequent drinkers. There was no clear relationship for women, however higher rates of sickness absence were found in non-drinkers.
Absenteeism↗
Magnitude and causes of mortality differences between married and unmarried men.
STUDY OBJECTIVE: To determine the effect of marital status on mortality for men. In particular, to examine whether subgroups of unmarried men (widowed, single, and divorced/separated men) have a similar mortality to married men. DESIGN: Cohort study. SETTING: Whitehall civil service, London, between 1967 and 1969. PARTICIPANTS: A total of 18,403 men aged 40-64 years with 18 years' follow up. MEASUREMENTS AND MAIN RESULTS: Cause-specific mortality rates and risk factors at baseline were determined. Overall mortality was greater for all groups of unmarried men. Patterns of mortality were different in the subgroups of unmarried men. Widowed men had a significantly greater risk of dying from ischaemic heart disease (relative risk (RR) 1.46, 95% confidence interval (CI) 1.08, 1.97) which persisted after exclusion of deaths that occurred in the first two years. Divorced men had greater cancer mortality (RR 1.49; 95% CI 1.06, 2.10) that could not be explained simply by their greater consumption of cigarettes. The initial increased mortality for single men was no longer evident after adjustment for other risk factors, suggesting that single status in itself may not increase the risk. The risk for single men may have been underestimated, however, by over adjustment for possible intermediary factors. CONCLUSIONS: Previous studies, which have examined total mortality only or have grouped all unmarried men, have masked interesting differences in the cause of death between subgroups of unmarried men. The extent to which the findings are explicable by psychosocial factors or the role of other environmental factors, which may also differ in relation to marital status, is unclear. Future work should not assume that all unmarried men have similar mortality risks and must examine the life course of each subgroup to advance our understanding of the possible causal role of marital status in disease aetiology.
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Relation of plasma triglyceride and apoB levels to insulin-mediated suppression of nonesterified fatty acids. Possible explanation for sex differences in lipoprotein pattern.
To test whether a sex difference in insulin-mediated suppression of nonesterified fatty acids (NEFAs) could account for sex differences in plasma triglyceride levels, we studied 632 normoglycemic men and women of European and South Asian descent aged 40 to 69 years. Mean fasting NEFA levels were 19% higher in women than in men. Between fasting and 2 hours after a 75-g oral glucose load, NEFA levels fell by 69% in women and 55% in men, so that mean NEFA levels at 2 hours after loading were 19% lower in women than in men. Plasma triglyceride and apolipoprotein B levels were correlated with 2-hour NEFA levels in each sex and ethnic group, and these associations were independent of glucose, insulin, and central obesity. These results are consistent with experimental studies of the effects of insulin and NEFAs on hepatic production of triglycerides and apolipoprotein B. Suppression of NEFA levels in response to insulin is greater in women than in men, and this may account for some of the sex differences in lipoprotein pattern and coronary heart disease risk.
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Association of early-onset coronary heart disease in South Asian men with glucose intolerance and hyperinsulinemia.
BACKGROUND: Rates of coronary heart disease are higher in South Asians (Indians, Pakistanis, and Bangladeshis) settled overseas than in other ethnic groups. We tested the hypothesis that this excess risk results from metabolic disturbances associated with insulin resistance. METHODS AND RESULTS: There were 1,421 South Asian men and 1,515 European men aged 40-69 years in London examined in the Southall Study. Prevalence of ischemic ECG abnormalities was higher in South Asians than in Europeans (17% versus 12%, p < 0.001), with an excess of major Q waves (Minnesota codes 1-1 or 1-2) in younger South Asian men (p = 0.01 for the age-ethnicity interaction). Major Q waves were strongly associated with glucose intolerance and hyperinsulinemia in younger South Asians; these factors accounted statistically for 73% of major Q waves in those aged 40-54 years. Age-standardized prevalence of a positive history of coronary heart disease was similar in South Asians and Europeans (8.5% versus 8.2%, NS), and positive history without Q waves was not associated with glucose intolerance or hyperinsulinemia in South Asians. Smoking rates and average plasma cholesterol were lower in South Asians than in Europeans; in a logistic model controlling for smoking and cholesterol, the odds ratio for major Q waves in South Asians compared with Europeans was 2.4 (95% CI, 1.5-3.8). Adjusting for glucose intolerance and hyperinsulinemia reduced this ratio to 1.5 (95% CI, 0.9-2.5). CONCLUSIONS: These results are consistent with the hypothesis that insulin resistance underlies the high coronary risk in South Asian people and strengthen the evidence for a fundamental role of this metabolic pattern in the etiology of coronary heart disease.
Adult↗
Resting and ambulatory blood pressure differences in Afro-Caribbeans and Europeans.
To investigate why mortality from stroke in people of Afro-Caribbean origin is twice the average for England and Wales, we examined 1166 European and Afro-Caribbean people in London. Age-standardized median systolic blood pressure was 6 mm Hg higher (128 versus 122 mm Hg) in Afro-Caribbean than European men and 17 mm Hg higher (135 versus 118 mm Hg) in Afro-Caribbean than European women. Migrants from West Africa and the Caribbean had similar blood pressures. Body mass index was higher in Afro-Caribbean than European women, accounting for 4 mm Hg of the systolic difference. Diabetes prevalence was 16% in Afro-Caribbeans and 5% in Europeans (P < .001), accounting for 1 mm Hg of the difference in systolic pressure in men and 2 mm Hg in women. In participants not taking antihypertensive medication, mean fall in ambulatory systolic pressure between daytime and nighttime, adjusted for resting blood pressures, was 24 mm Hg in Europeans and 18 mm Hg in Afro-Caribbeans (P = .05), and percent day-night fall in systolic blood pressure adjusted for resting systolic pressure was 17% in Europeans and 12% in Afro-Caribbeans (P < .05). This difference persisted when men and women and normotensive and hypertensive individuals were examined separately. We estimate that the differences in blood pressure between Afro-Caribbeans and Europeans may be enough to account for ethnic differences in stroke mortality in women but not men. The reasons for the high prevalence of hypertension and related morbidity in this and other populations of African descent remain to be established.
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Cancer in Italian migrant populations. England and Wales: mortality.
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Adolescent↗