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April 16', "4'i979 MEMORANDUM W. T~. Hoyt Leonard S. Zahn CC: A'1' WI7Ci RCH . SUBJECT: Annual Conference on Cardiovascular Disease Epidemiology New Orleans, March 19-21, 1979 -This meeting was opened tothe press for the first time in its 19-year history and the American Heart Associatiom, whose Epidemiology Council cosponsored the conference along with the National Heart,, Lung andi B1ood Institute, se~~t~ uupland~ manne~~dia press room. Press coverage consisted of.the medical trade*press„ l'ocal. papers and nEws wire b•;.ureaus,, and a medical wr iter from ;._ the "New York Time's. "' _ , ::. , s:. . _ . ._. .: . , . . ,.... - I had been told at the 1978 meeting that thelre'were pressures to permit the press to coveir;' these pressures were internal only.. There was fear that researchers, knowing,press people were present, might feel restrained in.itheir comments; on the contrary, there was the usual effort byvariousscientiststol$et publicity for their papers. . Knowing that the' meeting would be public may have prompted itss organizers to have a session on u'Smmoking and Health'"' (three papers, see below), which did not attract any attention, at least in the lay press. However,;" ][ expect one or more medical public- ations will carry something before long. 1. "Smoking and early menopause : the LRC Program" -- Judith Hill, Oklahoma City. Coronary heart disease mortality is much more;fre~quent in males than femallesunder~ age 50, Hill o!pened'.~ SinWe menopause o'ccurs n'ear the age when the'rate of female deaths from heart.disease begins to, increase„*hormonal factors that are protective-for women ddring,their productive years have been sug- gested as a possible explanation for this difference. Smoking has long, beerr accepted as a ma,j'or risk factor in heart disease, Hill continue'd. .][f' smoking, is associated with earl- ier menopause, this could help explain the changing coronary risk that.appears to accompany menopause. ; . Hill described a study encompassing 374 white womenibetween 45'and 55 years of age in 10 communities who were participants r~ in the so-called'Prevalence'Study'of the Lipid ResearchiC'linics ~ (LRC)1 Program. A rel'ationship was' found between cigarette' smok- w in&and early menopauuse among' these women, she sa,'id.. VW_ ~ ~.~Y ]~'i PU9L!IC RELATIONS~.COUNSEL - - ~~~ andA!ssociate.%lnc (P. 0. BOX 223) 13 LINCO[f+l ROAD' • GREAT NECNC, NiYI 11021 •(212)'895-7445'

2. More than half the womenicompleting natural menopause before age 50 smoked cig,arettes as opposed'to slightly more than a fourth of those continuing to have menstrual cycles. Heavy smokers were more likely to be postmenopausal than light smokers. Ex-smokers were more likely to have completed menopause before age 50'than women who had never smoked. There may be some common factor of factors that cause both leaner group. ma"ss,,,more of the leaner worrien were postmenopausal withi.n Eachl' age group. However, the proportion of smokers was higher in the. When the women were divided intol.two groups based on body menopause, ' this appeared to be due to the effect` of smoking. The same pattern wais found for alcohol use,, Hill said. Women postmenopausal before age 50 were three times as likely to drink four or more ounces of alcohol per week as abstaiiners. Alcohol use, however„'tended!to accompany smoking, Hill said. In other words, she 'addedi, though drinkers were found toe have an earlier tiions or alter sex hormone metabolism. Smoking may lower high density lipoprotein cholesterol levels (a suppose.d protective' factor in heart disease)'. . smo:xing and early menopause,, Hill continued. 'Perhaps there!are substances in smoke that affect the pituitary or ovarian fwnc- "'Obviously,, the association between smoking and early meno- pause is not clear and' requires further study, " she said at the end of her presentation. During Qland A, an unidentified physician noted that some women mature early and take up smoking earlier. Such women, he -said,, usually take up many things -- the ''gill,n alcohol, etc. -indiicating they are somehow different tharYiother women. It seems difficult.to pul'1 out just the.one habit (,factor), of smoking in, regard to early menopause,; he said. Hill agreed that it was a complicated matter. 2'. "Effect of diet and smoking on saliva and serum thiocya- natesr" -- Terry F. Pechacek, Minneapolis. This paper described a study to show that smoking-health researchers will have to be careful to assess diet in determining smoke exposure as measured. by thiocyanate (,SCN), levels. Smokers have elevated SCN levels, Pechacek said. The SCN measure has become widely used tolquarttifyT habitual smoke expo- sure aznd to validate sel!f-reportedlabstinence. (SCN levels de- C cline slowely after smoking is-'ended and can be easily measured W in urine, saliva or blood samples.) ~ ~ .Recent studies of'liarge groups of smokers and nonsmokers I1'a have shown overlaps between the distributions of'SCN'in the two ' W sI

groups. All smokers have high SCN levels, P'echacek said, but some nonsmokers also have elevated levels. The so-called "'false positives" m9y result from exposure to cyanide or cyanide gases, produce elevated SCN levels has not been showniin controlled feeding, experiments. .but it has been widely believed that high levels in nonsmokers come from eating,certain foods which~contain small amounts of cyanid'e or SCN (e.g., cabbage, cauliflower, broccoli, turnips,, rutabagas, or almond's). However, the ability of such foods to high in SCN),, whole grains (low in SCN)', and aisugar control (no . were : leafy vegetables (high in SCN)',, root vegetables (moderately diietary supplements along with a basic 'diet. The supplements -The diet was corutrolled by alcentral kitchen. All were fed four . A 12-week study was done with 16 subjects divided' into four groups of four.4one smoker and three nonsmokers in each group). SCN')i . 7'.. _ .. . _ sons smoking,20 or more cigarettes daily., for three weeks, but all 12 had values over 100 after eating, leafy vegetables. I1m fact, Pechacek said, all 12 nonsmokers had SCN levels as highas or higher than tho,se usually seen in per- of 12' nonsmokers had values over 1100 after eating root vegetables . An SCN level of 1!00 micomioles per liter in serum is commonly defined as the eutoff betweenismokers and nonsmokers. Only two 'nips) produced a much smaller effect. (,beets,.carrots„ sweet.potatoes„ parsnips, rutabagas, and tur- -in SCN levels among nonsmokers. Hmwever, the root vegetables ~cauliflowe~r~,, spinach) pr~oduced~~"re~~liab~~le!and dramatic'"~ elevations -: The leafy vegetables Q,cabbage, broccoli, brussels sprouts, ever, he added, the study showed that nonsmokers eating large quantities of leafy vegetables daily for three weeks will have SCN levels similar to those of smokers. Therefore, more care ..will need toibe taken tolassess recent dietary history,, if SCN is to be used as measure of smoke exposure. the study have little medical significance,, Pechacek said. How- Elevated SCN .levels like those seeniin the nonsmokers in 3'. r"Reduction of chronic d'isease risk factors in childhood. The "Know Your Body" pro ject (1976'-78') n-- C'har]les h!. Arnold, New York. This study followed 1,2512 students in six. Nlew Y.ork City area school districts for three years; the,students were part of a project aimed at red!ucing,the prevalence of "clinical values'''' associated' with chronic disease risk in ad'alts. A gen- eral health education program and a smaller intensive education `program were used to reduce prevalence in children with high ~ values of cholesterol, cigarette smoki:ng,,, physical inactivity, QrJ and obesity. '~ Arnold reported these findings to date: the school-based

4. prevention program is feasible and acceptable to the students; reduction of elevated1val'ues occurred with "intensive intervention'r involving smd`lil groups of' students ; the general health education program itself produced little apparent reductioni.in children with extreme values for their age and sex. : . .. - . . . . : ~:--. (The "New York Times"' writer at the meeting interviewedl Arnold!, who is with the American Health Foundation, and!wrote a story on the study. Apparently it was not sent to the paper or, if' it was, it did not appear in print. Certain aspects of the study were discussed with the writer.) 4. "Physical activity and the risk of coronary heart disease" Ancel Keys, Minneapolis. In this report to whose title he added the words C'a,nd premature death, " Keys (now living, in Italy) gave s~ome~~ de~tailso~f~ physical activity findings in th~e~ S~even C~~ountiries~ ' Study which, he said,, is being published (Harvard University Press). Retrospective studies showing lower coronary deathrates in men in physically active occupations led to, the Seven Countries _ ; . ., _, , . .. Stud y• .. The starting population consisted of 121,763 meniaged 40-59 in 16.cohorts in seven nations. At entry 2/ of the men were judgedd to have CHD andi 5% had some kind of CuD1. These were excluded from the analysis of'the incidence of CHD and death. After 10, years, among men free of CVID' at entry, 1,, 2$Q were dead,,. 29© from CHID. . Including, non-fatal cases, diagnosis of the disease had been givenn to 9'13' men. The study found that among,suggested risk factors for CHD, physical activity was "r'uniq;ue"' in showing d'ifferent, inconsistent relationships with the incidence of coronary disease in various areas and cohorts. ][n general„ the 10-year experience showed that age, arterial blood pressure, serumicholesterol, and cigarette„ smoking, in that order, were major risk factors, while relative weight and body fatness were without significance. . How about t e risk assocated with habitual physical activity?'. "Clearly, there is no universal rule of i * ncreasing, risk with de- creasing habitual. physical activity,"' Keys said. "I conclude that sedentary occupation is not a primary„ independent risk factor." 5. '''physical exercise and the prevention of' heart attack'r' -- R'alp~h S., Paffenbarger, Stanford, Cal. Mbstof Faffenbarger 's, presentatiion dealt with his stud'y of 16,900 Harvard alumni. He first gave alfcw details of his study of San Franci sco, longshore-O men who, he said, had 5©% fewer fatal heart attacks than workers C03 who expended fewer calories per day. What may be protective bene-~ . fits of strenuous activity remained effective at all ages and ~ wereindependentof'other riskfactors such as c .~ k r ae,Iing, smo

5 obesity,, high blood pressure or high blood glucose levels, Pafifen- barger said., Data from the Harvard alumni study .show that if' all had exer- cised more vigorously, the number-of.heart attacks in the group would have been reduced by 26/„ he said. Avoiding,cigarette smok- ing, wouldihave produced a$59o reduction, he said, but remission of hypertension only a 16/ redtuctiion because hypertensives con- stituted a smaller segment of the group thandid smokers. Since the experience of the alumni may well resemble that of' th~e!general pubilic~,~ _Pa~f'fenbarger~ cont~inu~ed',~ n'th~e~ implication ~ is~ clear that suitable programs of intervention mig1'Lt reduced heartt attack rates nationally by at least 5i09'a."1. . "Work tension and. incid!ence of' coronary heart disease" -- Richard S. Shekelle, Chicago. Work tension seems to ble related to increased'risk of CHD, Shekelle said in reporting data from the Western Electric Health Study which began in 1957. The final- group, of workers in the study totaled 2,052 ' men; 543' ( 26 . 5/') of whom had responded ""1rue"' to the question, I'll work urLder a great deal of tension. '' These men had' 1. 6 times greater risk of' developing ChID1in a,1a1-year period than did men who answered "'Fa1.se" to the question. Further analysis showed'that the association couldInot b~le:e~xp]laiinedl b~y~ variation ~ in blood pressure, cholesterol levels, age, and' cigarette smoking, Shekelle saidl., While the study has some obvious limitations, he said, the findings emphasize the need for further research to define more clearly various work factors and subjective reaponses to them. For those in whom work tension is prominent -- and'particular]ly for those with increased CHD risk due to smoking, high cholesterol levels and hypertension -- "'it would seemiprudient to recommend a programidesi:gned to improve personal skills in managing stress as part of an overall preventive cardiology regi~men."' 7. Twolstudies (one U.S.,, the other from Yugoslavia) ) were re- portedd claiming a beneficial effect from moderate alcohol intake. A third' study reported alcohol consumption appears to increase HDL levels.. The Yugoslav study noted, however, that alcohol drink- ing, was positively related tolthe incidence of' deaths from stroke, accidents and violence. (There were warnings of damage from ex- cessive drinking.) ~ 8. Margaret Oalmann of New Orleans reported aniautopsy study of' 566, area men aged 25-44 years. A significant relationiwais found between post mortem cholesterol and the extent of coronary artery raised lesions for white but not for black men. The reason (~ for the racial difference is not known,, she said.. ~ --- ~ M:,

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