More salt, please. The DASH Steering Committee.
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Blood Pressure↗
Biomedical subjects
W M Vollmer
Publications and source records attributed to W M Vollmer.
Relationship between lung function and blood pressure in Chinese men and women of Beijing and Guangzhou. PRC-USA Cardiovascular and Cardiopulmonary Epidemiology Research Group.
BACKGROUND: Previous studies of western populations have shown an inverse association between lung function and blood pressure. METHODS: As part of a People's Republic of China-United States cardiopulmonary epidemiology study, we investigated the cross-sectional relationship between lung function and blood pressure in 6757 Chinese men and women, aged 35-54, from Beijing and Guangzhou, China. We also evaluated the longitudinal association between lung function and incident hypertension among 4818 initially normotensive subjects followed up between 2 and 4 years later. RESULTS: In our cross-sectional analyses of baseline data, lung function varied inversely with baseline systolic (SBP) and diastolic blood pressure (DBP) in all women and in Beijing men. This association held for absolute and height-standardized forced vital capacity (FVC) and one-second forced expiratory volume (FEV1) (correlations: 0.10, -0.18, P < 0.0001), but was weaker after adjustment for age (correlations: -0.02, -0.11). The longitudinal follow-up showed that lower initial lung function levels were associated with a higher incidence of hypertension (SBP > or = 140 mmHg or DBP > or = 90 mmHg or currently using antihypertensive medications), but only among women in Guangzhou. Relative risks for hypertension incidence for those in the two lowest quintiles for FEV1 and FVC, compared to those in the two highest quintiles, ranged from 1.9 to 2.3 for Guangzhou women and from 0.9 to 1.4 for all other gender-city subgroups. Logistic regression analyses adjusting for age, baseline SBP, body mass index, smoking, education, and urban versus rural setting generally confirmed these patterns. CONCLUSIONS: These results suggest a statistically significant, though weak, inverse relationship between lung function and blood pressure in Chinese men and women. This association is largely attributable to age and is present prospectively only in women.
Adult↗
Nurses' and pharmacists' exposure to antineoplastic drugs: findings from industrial hygiene scans and urine mutagenicity tests.
Data from 83 nurses and pharmacists handling antineoplastic drugs and 35 nurse/pharmacist controls who participated in a national study of antineoplastic drug-handling risks were examined to investigate antineoplastic drug exposure. Measures of external exposure included self-completion drug logs and industrial hygiene scans conducted in clinical settings. Internal exposure was measured by urine mutagenicity tests on end-of-week 24-hour urine specimens. To control for potential confounders, the staff was asked to complete food and hobby diaries and to avoid identified mutagenic substances for 1 week before collection of 24-hour urine samples. On the scans of the drug handlers, 13% showed one or more spots of drug contamination on gloved and ungloved hands, gowns, or shoes. Of the 24-hour urine samples, 15% were mutagenic for Salmonella typhimurium: Rates did not differ significantly for drug handlers and controls. Among nurses who both prepared and administered antineoplastics, those with positive mutagenicity tests handled more doses of the drugs, used less skin protection, and had more skin contact with the drugs than those with negative tests. Nurses who only administered the drugs and had positive mutagenicity tests handled fewer doses of drugs than those with negative tests, but they also reported less use of protection and more skin contact. For both groups of nurses, skin contact with antineoplastics was associated with positive mutagenicity test results (p < 0.01).
Adult↗
Characteristics of patients with asthma within a large HMO: a comparison by age and gender.
Adequate information about characteristics of asthmatic patients in large health maintenance organizations (HMOs) is still lacking. As part of an ongoing longitudinal study, baseline data were collected on 914 individuals aged 3 to 55 yr with physician-diagnosed asthma within a large HMO, Kaiser Permanente, NW Region. There were no significant differences between men and women in post-bronchodilator FEV1 when expressed as percent (%) predicted yet women with asthma reported more daytime and nocturnal symptoms than men (p = 0.002), and worse quality of life in all but three of 14 subscales in two asthma quality of life instruments. Specifically, women in the 35-55 yr age group uniformly reported worse physical functioning on the SF-36 quality of life scale (71 +/- 23 versus 85 +/- 18; p = 0.001), social functioning (73 +/- 21 versus 77 +/- 20; p = 0.016), and bodily pain (63 +/- 27 versus 72 +/- 24; p < 0.001). Also these women reported use of more health care (p = 0.002) and more medications for asthma than men (p < 0.01). Our data suggest that men and women respond differently to their asthma, and observed gender differences in various measures of asthma such as hospital admissions, quality of life, and use of metered dose inhalers (MDIs), may be related to this difference in response to disease, rather than to real differences in the disease between men and women. Understanding gender related differences in response to a chronic disease such as asthma is important in tailoring an education and management plan to each individual patient.
Activities of Daily Living↗
20-year trends in the prevalence of asthma and chronic airflow obstruction in an HMO.
Although asthma is on the rise in the United States and elsewhere, data on age-sex-specific patterns of change in various types of health care utilization are scarce. We report on 20-yr trends in the treated prevalence of asthma among members of a large health maintenance organization. Data are presented separately for each of six age-sex categories, and include both the treated prevalence of asthma as well as the treated prevalence of the broader category of chronic airflow obstruction (CAO), defined as asthma, chronic bronchitis, or emphysema. During the period 1967-1987 the treated prevalence of asthma and CAO increased significantly in all age-sex categories except males aged 65 and older. These patterns are in contrast to previous studies of this population that showed that increases in asthma hospitalizations and hospital-based episodes of care were limited primarily to young boys. Not only do these findings support other evidence of a real increase in asthma prevalence, but they also highlight the risks associated with drawing inferences about changing disease epidemiology based on a single type of health care utilization.
Adolescent↗
Recruitment and retention of minority participants in the DASH controlled feeding trial. DASH Collaborative Research Group. Dietary Approaches to Stop Hypertension.
The Dietary Approaches to Stop Hypertension (DASH) study was a National Heart, Lung, and Blood Institute multicenter trial that compared the impact of three dietary patterns on blood pressure (BP) among adults with high normal blood pressure or mild (Stage I) hypertension. DASH's high minority representation (two-thirds of the 459 randomized participants came from minority populations, and 60% of the cohort were African American) offered a valuable opportunity to assess factors affecting minority enrollment and retention in clinical trials of lifestyle modification. Recruitment strategies included targeted mailings to specific groups, mass mailings, community and worksite screenings, and mass media advertising; the four DASH clinical centers also reimbursed participants from $150 to $160. The most productive recruitment strategies tended to be mass mailings directed at a broad audience that was weighted toward, but not limited to, minority participants. DASH's African-American participants overwhelmingly (89%) cited health and dietary factors, such as learning more about blood pressure and healthy eating habits, as their primary reason for participating, while only six percent listed the financial incentives as their primary reason for participating. Eighty-eight percent of African-American respondents reported they would participate again in a similar study. The insights from DASH should help inform future efforts to recruit minority participants.
Adult↗
Specialty differences in the management of asthma. A cross-sectional assessment of allergists' patients and generalists' patients in a large HMO.
OBJECTIVE: To examine the differences in medical management and quality of life between patients with asthma who receive their primary asthma care from allergists and those who receive their care from generalists in a large health maintenance organization (HMO). METHODS: We conducted a cross-sectional study of patients with asthma in a large HMO (Kaiser Permanente, Northwest Region, Portland, Ore). Participants were 392 individuals aged 15 through 55 years with physician-diagnosed asthma, taking antiasthma medications, reporting current asthma symptoms, and receiving asthma care from an allergist or from a generalist. Primary outcomes include characteristics of asthma, health care utilization, and quality of life. RESULTS: Patients cared for by allergists tended to have more severe asthma than those cared for by generalists (P < .01). The allergists' patients tended to be older (38.6 +/- 9.6 years vs 35.7 +/- 12.6 years, P < .01), more atopic (91% vs 78%, P < .01), and more likely to report perennial (rather than seasonal) asthma (26% vs 36%, P < .04) than the generalists' patients. Patients receiving their primary asthma care from an allergist were considerably more likely than generalists' patients to report using inhaled anti-inflammatory agents (P < .01), oral steroids (P < .01), and regular (daily) breathing medications to control their asthma (P < .01). Allergists' patients were more likely to have asthma exacerbations treated in a clinic setting rather than an emergency department (P < .01). Furthermore, allergists' patients reported significantly improved quality of life as measured by several dimensions of the SF-36 scale (physical functioning, role emotional, bodily pain, and general health; P < .05). CONCLUSIONS: These findings suggest that specialist care of asthma is of benefit for patients with asthma in a large HMO. Specifically, the allergists' patients conformed more closely to national asthma management guidelines and reported better quality of life than did the generalists' patients.
Adolescent↗
A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group.
BACKGROUND: It is known that obesity, sodium intake, and alcohol consumption factors influence blood pressure. In this clinical trial, Dietary Approaches to Stop Hypertension, we assessed the effects of dietary patterns on blood pressure. METHODS: We enrolled 459 adults with systolic blood pressures of less than 160 mm Hg and diastolic blood pressures of 80 to 95 mm Hg. For three weeks, the subjects were fed a control diet that was low in fruits, vegetables, and dairy products, with a fat content typical of the average diet in the United States. They were then randomly assigned to receive for eight weeks the control diet, a diet rich in fruits and vegetables, or a "combination" diet rich in fruits, vegetables, and low-fat dairy products and with reduced saturated and total fat. Sodium intake and body weight were maintained at constant levels. RESULTS: At base line, the mean (+/-SD) systolic and diastolic blood pressures were 131.3+/-10.8 mm Hg and 84.7+/-4.7 mm Hg, respectively. The combination diet reduced systolic and diastolic blood pressure by 5.5 and 3.0 mm Hg more, respectively, than the control diet (P<0.001 for each); the fruits-and-vegetables diet reduced systolic blood pressure by 2.8 mm Hg more (P<0.001) and diastolic blood pressure by 1.1 mm Hg more than the control diet (P=0.07). Among the 133 subjects with hypertension (systolic pressure, > or =140 mm Hg; diastolic pressure, > or =90 mm Hg; or both), the combination diet reduced systolic and diastolic blood pressure by 11.4 and 5.5 mm Hg more, respectively, than the control diet (P<0.001 for each); among the 326 subjects without hypertension, the corresponding reductions were 3.5 mm Hg (P<0.001) and 2.1 mm Hg (P=0.003). CONCLUSIONS: A diet rich in fruits, vegetables, and low-fat dairy foods and with reduced saturated and total fat can substantially lower blood pressure. This diet offers an additional nutritional approach to preventing and treating hypertension.
Adult↗
Self-reported food reactions and their associations with asthma.
The role of food reactions in asthma has not been well described. The objectives of this study were to evaluate the types of self-reported reactions to foods in asthmatic patients, and to determine the association between self-reported food reactions and self-reported severity of asthma and asthma health care utilization. We characterized 914 patients, aged 3-55 years, in a large health maintenance organization. We characterized the patients according to demographic data (age, sex, occupation, SES, marital status) and their asthma according to duration, triggers, severity (symptoms, FEV1 percentage predicted) and presence of atopy. Overall, 414 (45.3%) participants, primarily women, reported adverse reactions to food, particularly milk, red wine, eggs, chocolate, and peanuts. Those with food reactions were more likely to report having ever been hospitalized for breathing problems than those without food reactions (31% vs. 22%, two-tailed p = 0.004) although their asthma was not worse. Self-reported food reactions, particularly in females, may be associated with increased asthma health care utilization, and such patients may require closer health care management.
Adolescent↗
Periodicity of asthma, emphysema, and chronic bronchitis in a northwest health maintenance organization.
STUDY OBJECTIVE: Since seasonal patterns in morbidity may identify triggers provoking hospital-based care for airflow obstruction, this study examined seasonal variation in patterns of hospitalizations for asthma, chronic bronchitis, and emphysema. DESIGN AND SETTING: The data for this analysis were derived from the abstracted medical records of a large health maintenance organization, Kaiser Permanente, Northwest region, over the period 1979 to 1987. PATIENTS: In all, 2,060 primary hospital discharges for asthma and 1,121 primary hospital discharges for the combination chronic bronchitis/emphysema were observed. RESULTS: The monthly patterns varied for asthma and chronic bronchitis/emphysema, and also varied by age and sex. For young children 0 to 14 years, asthma hospitalizations peaked primarily in the fall. In contrast, for young children 0 to 14 years, hospitalizations for chronic bronchitis/ emphysema peaked in the fall/winter months. Seasonal variation decreased as age increased for chronic bronchitis/emphysema, such that for the 65+ year group, there was no seasonal variation. CONCLUSION: A better understanding of the causes of the age-specific seasonal patterns in these obstructive respiratory diseases may help to reduce the morbidity that is associated with them.
Adolescent↗
Use of an automated prescription database to identify individuals with asthma.
We used medication-dispensing information for 4 years (1/1/87 through 12/31/90) to examine the utilization of anti-asthma medications among 175,562 members of a large health maintenance organization. A total of 297,863 anti-asthma medications was dispensed during the study period, over one-half of which (55%) were beta-agonists, followed by aminophylline preparations (23%) and inhaled corticosteroids (13%). Next, we compared the predictive value of three algorithms for identifying individuals with asthma: (1) two or more beta-agonist dispensings, (2) both a beta-agonist and an inhaled corticosteroid dispensing, and (3) five or more total anti-asthma dispensings. We performed chart reviews for 40 subjects aged 5-45 years in each of these three groups and made a clinical judgment, based on all available information in the chart, as to whether each patient had asthma. Two levels of certainty were used: "any asthma" and "definite asthma." All 120 charts reviewed presented a clinical picture consistent with asthma. However, patients identified by the algorithm that included both a beta-agonist and an inhaled corticosteroid were more likely to meet our criteria for "definite" asthma and more likely to have moderate to severe asthma. These results demonstrate the feasibility of using an automated outpatient pharmacy database to identify patients with asthma.
Adolescent↗
Rationale and design of the Dietary Approaches to Stop Hypertension trial (DASH). A multicenter controlled-feeding study of dietary patterns to lower blood pressure.
Epidemiologic studies have found that dietary patterns characterized by high intakes of certain minerals and fiber are associated with low blood pressure. Dietary Approaches to Stop Hypertension (DASH) is a multicenter, randomized, controlled-feeding trial designed to test the effects on blood pressure of two such dietary patterns consumed for 8 weeks. The two experimental diets will be compared with each other and with a control dietary pattern that is relatively low in potassium, magnesium, calcium, and fiber, and has a fat and protein profile mirroring current consumption. The first experimental diet, arguably termed "ideal," is high in fruits, vegetables, whole cereal products, low-fat dairy products, fish, chicken, and lean meats designed to be low in saturated fat and cholesterol; moderately high in protein; and high in minerals and fiber. The second experimental diet tests the effect of fruits and vegetables alone. Its potassium, magnesium, and dietary fiber content will be at the same high levels as the ideal dietary pattern, while its fat, protein, and calcium content will resemble that of the control dietary pattern. The study population will consist of 456 healthy men and women, aged 22 years or older, with systolic blood pressure less than 160 mm Hg and diastolic blood pressure 80 to 95 mm Hg. African-American and other minority groups will comprise 67% of the population. Participants will eat one of the three dietary patterns. The DASH trial has unique features. First, dietary patterns rather than single nutrients are being tested. Second, all food for the experimental diets is provided to the participants using a standardized multicenter protocol. Because the dietary patterns are constructed with commonly consumed food items, the results, if positive, may be conveniently implemented in dietary recommendations to the general public.
Adult↗
Effects of cigarette smoking on lung function in four population samples in the People's Republic of China. The PRC-US Cardiovascular and Cardiopulmonary Epidemiology Research Group.
As part of an ongoing study of cardiopulmonary risk factors in the People's Republic of China, we conducted lung function tests and obtained information about smoking habits on 6,765 Chinese men and women 35 to 56 yr of age residing in or around Beijing in the north and in or around Guangzhou in the south. Within each region, separate urban and rural populations were recruited. This study examined the relationship between tobacco consumption (both manufactured cigarettes and leaf tobacco) and lung function in a subset of current smokers and never smokers who had acceptable lung function data. All methods were strictly standardized. Overall, tobacco smoking was associated with a statistically significant mean difference in FEV1 among men (-89 ml) and women (-52 ml) relative to never smokers after adjusting for age, height, and residence. Differences between smokers of cigarettes and smokers of leaf tobacco were not significant. Among the subset of smokers who smoked only cigarettes, this decrement increased with increasing duration of cigarette smoking, but it was small (-4 ml/yr of smoking for FEV1 for both men and women) in comparison with the effects of smoking reported from western countries. Although the smoking effect tended to increase with increasing dose, these differences were small and generally not statistically significant. The relatively small smoking effect in this study may result from differences between developed and developing countries in the cumulative dose of tobacco products. Alternative explanations or contributing factors such as racial differences in susceptibility and differences in the form and delivery of tobacco cannot be discounted.
Adult↗
Effects of smoking and smoking cessation on longitudinal decline in pulmonary function.
Effects of cigarette smoking and smoking cessation on rate of FEV1 decline over 6 yr were examined in 4,451 Japanese-American men from the Honolulu Heart Program who were 45 to 68 yr of age at baseline (1965-1968). Within-person regression was used to calculate annual change in FEV1. Rates of FEV1 decline varied strongly with smoking status and increased significantly with age. Overall, men who continued to smoke experienced steeper rates of decline compared with men who never smoked (-33 ml/yr versus -22 ml/yr, respectively; p = 0.0001). Rates of decline for those who quit smoking during the first 2 yr (-32 ml/yr) were nearly the same as those who continued smoking (-34 ml/yr). After quitting, their rates of decline diminished to a level (-19 ml/yr) similar to that of men who had never smoked (-21 ml/yr). FEV1 decline in continuing smokers was significantly associated with duration of smoking, whereas associations with intensity and pack-years were of borderline significance. Among 216 men with impaired pulmonary function, those who quit smoking had significantly slower rates of FEV1 decline than did those who continued smoking. Potential reasons for quitting included respiratory conditions and stroke. These results extend previous reports of accelerated rates of FEV1 decline in the persons who continue to smoke, and they indicate that smoking cessation leads to less steep rates of decline in pulmonary function over a short period of time in middle-aged men, as well as in men with established pulmonary impairment.
Aging↗
Body weight versus body fat distribution, adiposity, and frame size as predictors of bone density.
Weight is strongly associated with bone mineral density (BMD), but the mechanism of this effect is not well understood. Weight, height, hip-waist ratio, elbow breadth, adiposity, and BMD were measured in 6705 older women participating in the Study of Osteoporotic Fractures. Adiposity was measured by bioelectric impedance and BMD by single-photon (proximal and distal radius and calcaneus) and dual-energy x-ray absorptiometry (lumbar spine and proximal femur). Age-adjusted associations between weight and BMD were robust at all sites (R2 = 5.9-20.4%), but the addition of other anthropometric variables to the model only marginally improved the association. Adiposity explained a substantial fraction of the effect of weight on BMD, particularly at weight-bearing sites (36-62%). On the other hand, weight explained virtually all the variability of adiposity on BMD at weight-bearing sites (81-100%). At the radial measurement sites, adiposity had more substantial independent contributions. Weight did not seem to influence the relationship between BMD and age. In sum, at weight bearing-sites, the preponderance of the effect of weight on BMD is a direct result of mass effects rather than adiposity, whereas at non-weight-bearing sites, adiposity exerts more important effects, potentially mediated by metabolic factors.
Adipose Tissue↗
Recruiting hard-to-reach subjects: is it worth the effort?
Little information is available on the utility of spending resources to recruit hard-to-reach subjects. In particular, the compliance of such subjects with study protocols and visit schedules has not been documented. We present recruitment data from a two-phase survey of asthma prevalence in which a subset of respondents to a brief screening survey was recruited to attend a 90-min clinic visit. Although 39% of phase I subjects responding to initial contact attempts participated in the second phase of the study, this dropped to 12% among those responding to the sixth contact attempt (a phone follow-up). In studies in which the representatives of the sample is not of paramount importance, we see little benefit in aggressively seeking to recruit hard-to-reach subjects.
Asthma↗
Uses and limitations of mortality and health care utilization statistics in asthma research.
Mortality and health care utilization (HCU) statistics for asthma reflect both the acute and chronic aspects of this condition. We present a conceptual model that incorporates this dichotomy and also distinguishes between measures of disease occurrence (e.g., incidence and prevalence) and measures of disease management. We also discuss the use of mortality and HCU statistics in the literature, review their limitations and advantages, and make a number of general recommendations for their use.
Ambulatory Care↗