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In several clinical trials of interventions designed to lower plasma cholesterol, reductions in coronary heart disease mortality have been offset by an unexplained rise in suicides and other violent deaths. We have tried to find out whether depressive illness is related to low plasma cholesterol concentrations in men of 50 years and older. In 1985-87, Beck depression inventories were obtained from 1020 white men, aged 50-89 years, in the Rancho Bernardo, California, cohort. Disease history and behaviours were assessed by standard questionnaires. Plasma cholesterol and weight were measured at this time, as they had been in 1972-74. Among men aged 70 years and older, categorically defined depression was three times more common in the group with low plasma cholesterol (< 4.14 mmol/L) than in those with higher concentrations (5/31 [16%] vs 22/363 [6%]; p = 0.033). Depressive symptom scores correlated significantly and inversely with plasma cholesterol concentrations, even after adjustment for age, health status, number of chronic illnesses, number of medications, and exercise, as well as measured weight loss and change in plasma cholesterol in the previous 13 years. Our finding that low plasma cholesterol is associated with depressive symptoms in elderly men is compatible with observations that a very low total cholesterol may be related to suicide and violent death. Since cholesterol lowering in the general population is widely recommended, this observation warrants further investigation.

The infant feeding intentions of 64 primiparous, adolescent females, ages 14-18 years, were studied to assess factors which differentiated those who chose breastfeeding from those who did not. The study population consisted of 43 Hispanic, 9 black, 7 non-Hispanic white, and 5 Filipino or Southeast Asian subjects interviewed after delivery. Among the Hispanics, 31 primarily spoke Spanish, and 12 primarily spoke English. A total of 72% intended to breastfeed, and 22% planned to exclusively formula feed. Those teens who intended to breastfeed were significantly older, more often married, more likely to be Hispanic and Spanish speaking, and less likely to have been in school during the pregnancy. In addition, teens were more likely to choose breastfeeding if they had been breastfed themselves or exposed to other women who breastfed. These data suggest that the younger, non-Hispanic, single teen who is enrolled in school and lacking exposure to breastfeeding is the most in need of breastfeeding-promotion programs.

The relation between multiparity and lipid and lipoprotein levels was examined in a sample of 1275 Rancho Bernardo women aged 50-89. Number of pregnancies ranged from 0 to 13 with a mean of 2.1. Pregnancy was unrelated to high density lipoprotein cholesterol level in women with 4 or fewer pregnancies, but women with 5 or more pregnancies had significantly lower levels both before and after adjustment for age, obesity, diabetes, alcohol and cigarette consumption, exercise and estrogen use. After multiple regression analysis, women with 5 or more pregnancies had high density lipoprotein levels that were 4.9 mg/dl lower than women with 4 or fewer pregnancies. No differences in total cholesterol, low density lipoprotein cholesterol or triglyceride levels were observed by number of pregnancies. If confirmed by others, these results suggest that one factor mediating the previously reported relationship between multiparity and cardiovascular disease may be a decreased level of high density lipoprotein cholesterol.

Background: In recent years, an increasing number of women have been entering the labor force. It is known that in men, employment is related to heart disease risk, but there are few studies examining this association among women., Methods: The relation between employment status and heart disease risk factors including lipid and lipoprotein levels, systolic and diastolic blood pressure, fasting and postchallenge plasma glucose and insulin levels, was examined in 242 women aged 40 to 59 years, who were participants in the Rancho Bernardo Heart and Chronic Disease Survey. At the time of a follow-up clinic visit between 1984 and 1987, 46.7% were employed, primarily in managerial positions., Results: Employed women smoked fewer cigarettes, drank less alcohol, and exercised more than unemployed women, but these differences were not statistically significant. After adjustment for covariates, employed women had significantly lower total cholesterol and fasting plasma glucose levels than unemployed women. Differences on other biological variables, although not statistically significant, also favored the employed women., Conclusions: Results of this study suggest that middle-aged women employed in managerial positions are healthier than unemployed women.

We evaluated mortality and health services utilization in a prospective study of 630 older residents of a Southern California community. All participants were 65 years or older when initially evaluated in 1973-1975. In addition to being followed for vital status each year, participants were reinterviewed in 1984-1986 and asked about nursing home, hospital, and community-based care for the interim period. Current cigarette use in 1973-1975 was a significant predictor of mortality for both men and women. In addition, former smoking status (before 1973-1975) significantly predicted both mortality and hospital inpatient utilization in men and women combined. However, smoking was not significantly associated with nursing home utilization or use of three categories of community-based care services. More research is necessary to identify the relationship between cigarette smoking and outpatient service use. The findings for mortality and inpatient hospital service utilization reaffirm the hazards of cigarette smoking.

Objective: To examine the efficiency of fasting plasma glucose (FPG) as a screening test for non-insulin-dependent diabetes mellitus (NIDDM). RESEARCH AND METHODS DESIGN: A population-based evaluation was made of FPG as screening test for NIDDM in an upper middle-class white community of Rancho Bernardo, California. NIDDM was defined by 2-h postchallenge plasma glucose (PCPG) level greater than or equal to 11.1 mM, the cutoff point recommended by the World Health Organization. Participants comprised a population-based sample of 1851 men and women 50-79 yr of age that represented 80% of surviving participants surveyed between 1972 and 1974 for the Lipid Research Clinic Prevalence Study. Those with insulin-dependent diabetes were excluded., Results: Analyses were stratified by age after logistic regression indicated that FPG and age (but not gender) were significantly related to probability of disease. As FPG cutoff points increased, sensitivity and percentage of the population to be recalled for confirmation decreased, whereas specificity and positive predictive value increased. Negative predictive value was consistently in the 90% range. Specificity did not change with age. In contrast, at virtually every FPG cutoff point, sensitivity decreased with increasing age. For example, at FPG greater than or equal to 6.7 mM, sensitivity was 65.6% for those 50-64 yr of age and 40.0% for those 65-79 yr of age. At FPG greater than or equal to 7.2 mM, these sensitivities were 46.9 and 28.5%, respectively. Positive predictive value increased with increasing age, reflecting the increasing prevalence of NIDDM with age., Conclusions: Poorer sensitivity with increasing age reflects the fact that the numerator of the sensitivity equation is not affected by age (mean FPG did not vary significantly between age-groups), whereas the denominator increases with age (mean PCPG increased from 6.6 mM for subjects 50-64 yr of age to 8.2 mM for subjects 65-79 yr of age). Nevertheless, because the clinical significance of increasing PCPG with age in older adults is unknown, age-specific screening criteria probably are not warranted.

Objective: Prevalence rates of visual impairment and retinopathy were compared in 1992 people with normal glucose tolerance, impaired glucose tolerance (IGT), or newly diagnosed non-insulin-dependent diabetes mellitus (NIDDM)., Research Design and Methods: Glucose tolerance status was based on an oral glucose tolerance test after exclusion of those with a history of diabetes and/or diabetes medication use in an upper middle-class community of older white adults in southern California between 1984 and 1987., Results: Although many sex-specific comparisons were made between glucose tolerance groups, only a few emerged as statistically significant. Among those, women with IGT had significantly higher age-adjusted rates of visual impairment (10.8%) than women with normal glucose tolerance (4.4%). Among men, those with IGT had significantly higher age-adjusted rates of visual impairment (7.9%) than men with newly diagnosed NIDDM (4.0%)., Conclusions: Low frequencies of retinopathy were found in all three glucose tolerance groups.

The prevalence of depressive symptoms and its association with Type 2 (non-insulin-dependent) diabetes was examined in a population-based study of 1586 men and women aged 50 years or older. Men and women with previously diagnosed diabetes had significantly higher mean Beck Depression Inventory total, somatic subscale, and affective subscale scores than normal men and women and individuals with newly diagnosed diabetes. The age- and sex-adjusted rates of Inventory scores of 13 or greater among individuals with previously diagnosed diabetes was 3.7 times greater than the rates among individuals with newly diagnosed diabetes (p less than 0.05). Medication use and fasting plasma glucose were unrelated to symptom score. The number of other chronic conditions and age were significant independent predictors of depressive symptoms in all diabetic men and women. Results suggest that depressive symptoms in individuals with Type 2 diabetes may be related to awareness of diabetic condition in addition to poor health.

The relation between fasting plasma glucose and mortality from ischemic heart disease was examined in a population of 3,458 nondiabetics (aged 40-79 years) in Rancho Bernardo, California, who were free of heart disease at baseline and were followed for an average of 14 years, from 1972 to 1987. A linear increase of age-adjusted ischemic heart disease mortality rates with fasting glucose was observed in men, and a threshold relation at 110 mg/100 ml plasma glucose was observed in women. On the basis of Cox proportional hazards analysis, the observed sex differential in the association between plasma glucose and ischemic heart disease mortality proved to be statistically significant and independent of the effects of age, systolic blood pressure, body mass index, plasma cholesterol, plasma triglyceride, and, in women, estrogen use. In sex-specific multivariate models, interaction terms representing a threshold effect at glucose levels greater than or equal to 110 mg/100 ml were statistically significant in women (p = 0.007), but not in men, and interaction between sex and the glucose threshold term was observed in multivariate analysis of men and women combined (p = 0.07). The authors conclude that sex differences in the effect of fasting glycemia on ischemic heart disease mortality among nondiabetics exist and are unexplained. Elucidation may hold a key to the sex difference in heart disease and the relatively greater importance of diabetes and impaired glucose tolerance as risk factors for ischemic heart disease in women compared with men.

We report here the 14-year sex-specific effect of non-insulin-dependent diabetes mellitus on the risk of fatal ischemic heart disease in a geographically defined population of men and women aged 40 through 79 years. There were 207 men and 127 women who had diabetes at baseline based on medical history or fasting hyperglycemia. They were compared with 2137 adults who had fasting euglycemia and a negative personal and family history of diabetes. The relative hazard of ischemic heart disease death in diabetics vs nondiabetics was 1.8 in men and 3.3 in women, after adjusting for age, and 1.9 and 3.3, respectively, after adjusting for age, systolic blood pressure, cholesterol, body mass index, and cigarette smoking using the Cox regression model. The sex difference in the independent contribution of diabetes to fatal heart disease was largely explained by the persistently more favorable survival rate of women (than men) without diabetes.

Hyperinsulinemia has been proposed as the common pathogenetic mechanism of obesity, non-insulin-dependent diabetes mellitus, and hypertension. We examined the cross-sectional relationship between fasting and postchallenge insulin levels and hypertensive status in a population-based study of 653 men and 784 women, aged 50 to 93 years, in Rancho Bernardo, California. Hypertensive subjects had slightly but not significantly higher fasting plasma insulin levels than did normotensive subjects, but significantly higher postchallenge insulin levels. After stratification for obesity and glucose intolerance, there was no significant difference between the mean age-adjusted fasting or postchallenge insulin levels of those with and those without hypertension in 12 possible subgroups. Analysis of variance of both fasting and postchallenge insulin levels also failed to reveal a significant relationship between insulin and hypertensive status after adjusting for age, sex, body mass index, and diabetes. The current study does not support the hypothesis that insulin is independently associated with hypertension.

In 1986 the life expectancy at birth was 71.3 years for males and 78.3 years for females--providing a 7-year advantage for women. Although women live longer, it has been reported that they paradoxically experience more physical and psychological illnesses. In this article, we estimate the expected well-years or quality-adjusted life years for men and women in the general population. The data were obtained in a random sample of 1,034 residents of San Diego. The well-life expectancy uses standard life expectancies with adjustments for quality of life. The well-life expectancy for men was 59.8 years; for women, it was 62.7 years. Thus, the quality adjustment had significantly more impact on women (15.6 years) than on men (11.5 years). Age-specific estimates of health-related quality of life suggested a male advantage before age 45 and a female advantage after age 45. The benefits of well-years of life as a public health statistic are discussed.

The effect of alcohol use on risk of non-insulin-dependent diabetes mellitus was assessed in a defined population. A 24-hour recall of alcohol intake and past-week alcohol intake were obtained by separate interviewers between 1973 and 1975, and responses were coded by the Nutrition Coordinating Center, University of Minnesota. Of the 524 adults aged 30-79 years without diabetes at baseline, 31 men and 44 women were identified as diabetic by means of a glucose tolerance test (World Health Organization criteria) between 1984 and 1987. Men, but not women, who developed diabetes reported significantly more alcohol intake in the past week and in the past 24 hours. The highest rate of diabetes among alcohol users was in heavy drinkers--statistically significant only in men. Alcohol use remained a significant predictor of diabetes in men after adjustment for baseline age, body mass index (weight (kg)/height (m)2), cigarette smoking, family history of diabetes, and systolic blood pressure with a logistic regression model. The relative risk associated with past-week alcohol intake was 1.5 per 137.8 g; for past-24-hour alcohol intake, it was 1.5 per 24.5 g. Adjustment for baseline fasting plasma glucose and triglycerides did not change the results. Alcohol intake appears to be associated with risk of non-insulin-dependent diabetes mellitus in men.

In order to examine sex differences in the association of obesity with the risk of non-insulin dependent diabetes mellitus (NIDDM) when using the body mass index (BMI), we compared unisex body mass index classifications with sex-specific categories, as defined by the Metropolitan Life Tables, based on their utility in predicting the 12-year incidence of NIDDM in men and women. The present analysis included all 747 men and 969 women from a defined older caucasian population in Rancho Bernardo, California, who were 40 years of age or older at the baseline examination in 1972-1974 and who had complete diabetes-related data available then and between 1984-1987. The 12-year age-adjusted incidence rates for NIDDM increased with increasing BMI among women (all steps significant), but was significantly increased only in the most obese category of men (relative risk (RR) = 2.3, P less than 0.05 for men; RR = 3.8, P less than 0.001 for women). Men and women had nearly identical rates of NIDDM in this obese category. When identical (unisex) BMI cutpoints were used, results were the same; (RR = 2.4, P less than 0.05 for men; RR = 3.1, P less than 0.01 for women). These data indicate that unisex and sex-specific cutpoints for BMI identify the same sex-specific patterns of association between obesity and risk of NIDDM.

In the Rancho Bernardo, California population of older adults, the age-adjusted prevalence rate of self-reported arthritis was higher in women than men for all types combined (38.6 vs. 22.3%, p less than 0.05), and for osteoarthritis (18.1 vs 12.9%). Men and women with osteoarthritis and disabling arthritis were significantly more likely to report co-morbid conditions. Women with osteoarthritis were significantly less likely to drink alcohol and more likely to be taking estrogen replacement therapy. At 15 years of follow up, mortality rates were not significantly increased in men or women with arthritis or osteoarthritis compared to those without arthritis.

Rates of nursing home utilization between 1972 and 1986 were determined for 1,302 men and women living in an upper-middle-class community in Southern California. Leading diagnostic reasons for admission were dementia, cancer, and stroke, and the leading nondiagnostic reason for admission was an inability to carry out activities of daily living. In this cohort, rates of nursing home utilization increased with age. Women at all ages used nursing homes at a higher rate than men, although their probability of survival once admitted was greater. Admission rates were higher over time or prior to death than when observed cross-sectionally. Rates were highest in the year prior to death but declined at time of death.

Cardiovascular disease risk factors were measured 10-15 years (mean, 11.9 years) prior to the diagnosis of impaired glucose tolerance and non-insulin-dependent diabetes mellitus in Rancho Bernardo, California. There were 1,847 men and women aged 40-79 years who had no known diabetes or fasting hyperglycemia at baseline (1972-1974). At the follow-up examination (1984-1987), 1,115 men and women (60.4%) had normal glucose tolerance, 513 (27.8%) had impaired glucose tolerance, and 219 (11.9%) had non-insulin-dependent diabetes mellitus as defined by World Health Organization criteria. Rates of impaired glucose tolerance and non-insulin-dependent diabetes mellitus increased with age, and impaired glucose tolerance was approximately twice as common as non-insulin-dependent diabetes mellitus. Those with non-insulin-dependent diabetes mellitus were older and more overweight and had higher levels of blood pressure, fasting plasma glucose, and triglyceride at baseline than those whose glucose tolerance remained normal; those with impaired glucose tolerance generally had intermediate levels of the same risk factors. When it was examined in a prospective fashion, in general, the age-adjusted risk of non-insulin-dependent diabetes mellitus increased with increasing quartile of each risk factor, and the risk of non-insulin-dependent diabetes mellitus in a given quartile was greater than that for impaired glucose tolerance. Logistic regression analyses showed these factors to be positively associated with a subsequent diagnosis of impaired glucose tolerance as well as non-insulin-dependent diabetes mellitus in women, and to a lesser degree in men, independent of baseline age and body mass index (weight (kg)/height (m)2). These data illustrate that a less favorable cardiovascular risk factor profile precedes the diagnosis of both non-insulin-dependent diabetes mellitus and impaired glucose tolerance.

In a previous analysis from the Alameda County Study, it was observed that although men had higher heart disease mortality rates than women, there was no male excess in the prevalence of self-reported heart disease morbidity at baseline or in new reports of morbidity 9 years past baseline. This apparent contradiction might occur because women report less severe heart disease than men. In the present study, this hypothesis was evaluated by examining whether self-reported heart trouble was more strongly associated with subsequent heart disease mortality for men than for women in a representative sample of the population of Alameda County, California, selected in 1965 and followed for mortality for 19 years (n = 3,742). In a time-dependent Cox model, self-reported heart trouble was a stronger predictor of heart disease mortality for men, but only during the early years of follow-up (p = 0.00). This effect was due to a shorter time to death for men who reported heart trouble. The relative hazard for men reporting heart trouble was 6.6 (95% confidence interval (CI) 3.7-11.6) at baseline, declining to 3.2 (95% CI 2.2-4.5) by 5 years past baseline and 1.5 (95% CI 0.9-2.5) by 10 years past baseline. Self-reported heart trouble was a consistent predictor of subsequent heart disease mortality for women over the 19-year follow-up period (relative hazard = 2.0, 95% CI 1.4-2.8). Sex differences in the prognosis of self-reported heart trouble were masked in non-time-dependent analyses. These results illustrate that consideration of time dependence may be required for meaningful analysis of long-term cohort studies. Possible explanations of the shorter time to death for men who reported heart trouble are discussed.

The prevalence of ischemic heart disease (IHD) in older adults by glucose tolerance status was evaluated in 2,223 white men and women, aged 50-89 years, in the Rancho Bernardo cohort who were studied between 1984 and 1987. Impaired glucose tolerance (IGT) and non-insulin-dependent diabetes mellitus (NIDDM) were classified according to World Health Organization criteria. End points of ischemic heart disease were defined by Rose Questionnaire and resting electrocardiogram (ECG) according to the Minnesota Code. IHD by electrocardiographic changes was classified as asymptomatic (without history of chest pain or overt IHD) or symptomatic (with history). IHD by all criteria combined was significantly more common in men and women with NIDDM, and in women with IGT, than in those with normal glucose tolerance. The prevalence of myocardial infarction, defined by major Q wave, Rose Questionnaire chest pain criteria, or personal history, was higher in persons with NIDDM than in persons without; the difference was highly significant in women (odds ratio, 2.08 [1.22, 3.56]; p = 0.009). Angina pectoris was not significantly related to NIDDM or IGT in either sex. Electrocardiographic evidence of asymptomatic IHD was significantly more prevalent in both men and women with NIDDM as compared with those with normal glucose tolerance (odds ratios, 1.75 [1.10, 2.81] for men and 1.80 [1.07, 3.01] for women; p less than 0.05). This significant association persisted after excluding persons on digitlis or diuretic therapy and, in women, was also independent of the effect of major known IHD risk factors. These population-based data are consistent with clinical reports suggesting an association of diabetes with silent myocardial infarction or ischemia. The presence of ischemic resting electrocardiographic abnormalities in the asymptomatic diabetic patient is likely to have prognostic and therapeutic implications.

A cross-sectional study of the distribution of depressive symptoms and association between depressed mood and chronic illness was conducted in a geographically defined population in southern California of 1617 men and women aged 65 years and older. The prevalence of depressed mood for the total population was 5.2%. Women exhibited a significantly higher mean depressive symptom score and a prevalence rate almost twice that of men. Depressive symptoms were associated with several risk factors in both sexes, including age, self-perception of current health status, number of reported chronic diseases and medications and amount of exercise. However, the relationship between physical illness and depressive symptoms appeared to differ by sex with respect to the nature of the disease or disability and the type of medication currently used. These findings indicate that the risk of depression does not diminish with age among the elderly as other studies have suggested.

We examined the relationship of reproductive history to cholecystectomy in a population-based sample of 1093 women aged 50 years and older. Number of pregnancies ranged from 0 to 13. Age and obesity were each significantly and independently associated with an increased risk of cholecystectomy. When adjusted for differences in age and obesity, those who had had five or more pregnancies had a significantly increased risk of cholecystectomy. We conclude that an increased risk of gallbladder disease may follow either obesity or multiple pregnancies. One possibly unifying hypothesis for the obesity and pregnancy association is sustained hyperestrogenemia.

Endogenous androgens have been suggested as determinants of risk of prostatic cancer. To examine this possibility, baseline sex hormone levels were measured in 1008 men ages 40-79 years who had been followed for 14 years. There were 31 incident cases of prostatic cancer and 26 identified from death certificates with unknown dates of diagnosis. In this study, total testosterone, estrone, estradiol, and sex hormone-binding globulin were not related to prostate cancer, but plasma androstenedione showed a positive dose-response gradient. Age-adjusted relative risks of prostatic cancer for low (0-2.2 nM), middle (2.3-3.1 nM), and high (3.2+ nM) tertiles of androstenedione were 1.00, 1.34, and 1.98, respectively (P trend less than 0.05). The linear gradient of risk persisted after adjustment for age and body mass index. If confirmed, these data suggest that androstenedione might increase the occurrence of clinically manifest prostatic cancer.

The association between the size and structure of social networks and the prevalence of depressive symptoms was examined in a population-based study of 1615 men and women age 65 years and older. Age was significantly associated with marital status, social network index quartile, and the social relationship to the primary source of support. Women and men differed with respect to current marital status, number of close friends and relatives, frequency of face-to-face contact, and participation in voluntary associations and religious institutions. Regardless of their marital status, women were also less likely than men to point to a spouse as their primary source of support. Beck Depression Inventory mean scores and rates of depressive symptoms were inversely associated with social network index and participation in voluntary associations and religious institutions for both men and women. Individuals with no primary source of support or who depended on a relative had significantly higher than expected mean scores and rates of depressive symptoms. Both social network index and social distance to primary source of support were independently associated with depression after controlling for age, sex, and number of chronic conditions. Participation in voluntary associations, social distance from primary source of support, church membership, and number of close friends were also significant independent predictors of depressive symptoms. Results indicate that depressive symptoms are inversely associated with the size of social networks. The structure of these networks, in turn, is influenced by biological factors such as age, physical disability, and mortality of network members, and by culturally-determined rules that define the individuals and institutions available for support. However, these rules appear to differ for men and women.

The mortality risk associated with different sleeping patterns was assessed by use of the 1965 Human Population Laboratory survey of a random sample of 6928 adults in Alameda County, CA and a subsequent 9-year mortality follow-up. The analysis indicates that mortality rates from ischemic heart disease, cancer, stroke, and all causes combined were lowest for individuals sleeping 7 or 8 h per night. Men sleeping 6 h or less or 9 h or more had 1.7 times the total age-adjusted death rate of men sleeping 7 or 8 h per night. The comparable relative risk for women was 1.6. The association between sleeping patterns and all causes of mortality was found to be independent of self-reported trouble sleeping and self-reported physical health status at the time of the 1965 survey. Simultaneous adjustment for age, sex, race, socioeconomic status, physical health status, smoking history, physical inactivity, alcohol consumption, weight status, use of health services, social networks, and life satisfaction reduced the relative mortality risk associated with sleeping patterns to 1.3 (p less than or equal to 0.04).

This study investigated the impact of combining marital, parental, and occupational roles upon 18-year risk of mortality from all causes. The respondents were 3,700 participants in the Human Population Laboratory cohort ages 35-64 who completed a comprehensive health and psychosocial questionnaire in 1965 and were followed for mortality status through 1982. Employment status and type of employment were not found to predict mortality risk among women. Contrary to the multiple roles hypothesis, there was virtually no impact upon mortality of increasing numbers of children among employed women, except possibly among single working parents. The major impact of children was felt by housewives who had significantly elevated risks when a child was present in the home or when they had four or more children. Neither the number of children nor the presence of a child in the home affected mortality risk of men. Controlling for a variety of factors thought to be related to mortality in a logistic regression analysis did not change the foregoing relation.

In the United States, women live longer than men, and they have lower death rates at virtually every age and for most causes of death. The sex differential in mortality has been increasing since the early 1900s, especially for those 15-24 and 55-64 years of age. Since 1970, however, that trend has slowed for persons 45-74, and for the first time, the sex differential among those 55-64 was actually smaller in 1980 than in 1970. While women have lower age-specific death rates than men for most causes of death, among adults 65 years old and older, the leading causes of death are the same for men and women: heart disease, cancer, and stroke. Despite their continuing mortality advantage, women generally experience more illness than men. They report more self-perceived poor health up to age 60. It has been frequently suggested that women may be more willing to acknowledge and report illness than men. Sex differences in illness among the elderly persist, however, when physical examinations are used for assessment of population-based samples. Injuries, one of the few conditions more common among men, are more common among women after age 55. Among the elderly, women appear to have more conditions that are disabling, such as arthritis, while men have more life-threatening conditions, such as heart disease. Women also use more health services than men, and they are institutionalized more frequently in their later years. Future health service planning must take into consideration women's greater health service needs. Future research needs to determine why women have more illness than men and whether women's greater life expectancy is associated with a greater active life expectancy, or if they are merely experiencing more years of disability and dependency.

By using the 1965 Human Population Laboratory Survey of a random sample of 6928 adults in Alameda County, California, and a nine-year follow-up, mortality risk is examined by sex, while simultaneously controlling for 16 demographic and behavioral risk factors by a multiple logistic analysis. Risk factors include age, race, socioeconomic status, occupation, physical health status, use of health services, smoking, alcohol consumption, physical activity, weight, sleeping patterns, marital status, social contacts, church and group membership and life satisfaction. The prevalence and relative mortality risk of each factor combine to influence the sex differential. The unadjusted relative mortality risk for men compared to women is 1.5 (p less than or equal to 0.001). Adjustment for some factors (e.g., smoking and alcohol) decreases this difference, while other adjustments (e.g., for physical activity, physical health status and marital status) increase the difference. Adjustment for all 16 factors slightly increases the relative risk to 1.7 (p less than or equal to 0.001). These demographic and behavioral risk factors do not account for the overall sex difference in mortality rates. Examination of the interaction of biologic and behavioral risk factors may more fully explain the sex differential in mortality.

To determine the effect of parity on the later development of non-insulin-dependent diabetes mellitus or impaired glucose tolerance, we studied a population-based sample of 1186 women at least 40 years of age; those who had been given a diagnosis of diabetes mellitus before the age of 40 or who had insulin-dependent diabetes mellitus were excluded from the study. On the basis of the World Health Organization's criteria, 714 had normal glucose tolerance, 326 had impaired glucose tolerance, and 146 had non-insulin-dependent diabetes mellitus (NIDDM). After adjustment for age, obesity, and family history of diabetes, increased parity was associated with a significantly increased risk of both NIDDM (odds ratio, 1.16 [95 percent confidence interval, 1.04 to 1.29] per pregnancy) and impaired glucose tolerance (odds ratio 1.10 [95 percent confidence interval, 1.01 to 1.19] per pregnancy). Obesity, whether estimated by means of the body-mass index or the waist-hip ratio, was significantly associated with an increased risk of both NIDDM and impaired glucose tolerance, but this factor did not explain the association between parity and diabetes or impaired glucose tolerance; neither the maximal lifetime body-mass index nor the waist-hip ratio was significantly associated with parity in this cohort. We conclude that there is a slight increase in the risk of NIDDM or impaired glucose tolerance with increasing parity many years after childbearing and that this association is not explained by obesity.

The mortality attributable to ischemic heart disease as a result of cigarette smoking is greater of a community of older adults in southern California, the authors tested the hypothesis that nonsmoking women exposed to their husband's cigarette smoke would have an elevated risk of fatal ischemic heart disease. Married women aged 50-79 years who had never smoked cigarettes (n = 695) were classified according to the husband's self-reported smoking status at entry into the study: never, former, or current smoker. After 10 years, nonsmoking wives of current or former cigarette smokers had a higher total (p less than or equal to 0.05) and age-adjusted (p less than or equal to 0.10) death rate from ischemic heart disease than women whose husbands never smoked. After adjustment for differences in risk factors for heart disease, the relative risk for death from ischemic heart disease in nonsmoking women married to current or former cigarette smokers was 14.9 (p less than or equal to 0.10). These data are compatible with the hypothesis that passive cigarette smoking carries an excess risk of fatal ischemic heart disease.

Postmenopausal estrogen use and risk factors for heart disease were assessed in 1057 women, aged 50 to 79 years, who were enrolled in an ongoing study of residents of an upper-middle-class community. From 1984 through 1987, thirty-one percent of the women reported current estrogen use, a rate equivalent to that determined in one survey of the same population done from 1972 through 1974. Compared with nonusers, current users did not have a more favorable cardiac risk factor profile before use, but users were more likely to have had a surgically induced menopause and to have been estrogen users during the survey done from 1972 through 1974. Similar to our earlier findings, current estrogen use was associated with lower weight, diastolic blood pressure, and fasting plasma glucose level than nonuse. Levels of low-density lipoprotein cholesterol were inversely related to estrogen dose; levels of high-density lipoprotein cholesterol were positively related to the duration of use. In this cross-sectional study, blood pressure and lipoprotein and plasma glucose levels were similar in women receiving estrogen alone and in women receiving combination estrogen and progestin therapy.

The sex differential in mortality from all causes and ischemic heart disease is examined in an upper-middle class Caucasian community of 3516 adults in southern California, who were followed for a minimum of seven years. The influence of several demographic, behavioral, and biologic risk factors is simultaneously controlled for by means of a multiple logistic analysis. Risk factors include age, marital status, education, cigarette smoking, cholesterol, systolic blood pressure, fasting plasma glucose, and obesity. Both the prevalence and relative mortality risk associated with several risk factors differ by sex. Adjustment decreases the sex differential for mortality from 1.7 to 1.3 for all causes and from 4.8 to 2.4 for ischemic heart disease. When analysis is limited to healthy men and women, the adjusted sex differential in mortality is 1.2 for all causes and 2.0 for ischemic heart disease. Findings of this study are compared with two other population-based studies.

The associations between intake of coffee or decaffeinated coffee and plasma cholesterol and lipoprotein measurements were examined in a probability sample from a defined community of adults. The results were based on 24-hour dietary recall interviews and laboratory measurements carried out in 1972-1974 on 381 women and 320 men conducted as part of the La Jolla Lipid Research Clinic study. Intake of 8+ oz (230+ ml) of coffee per day was reported by 65% of women and 70% of men. Plasma cholesterol increased with increasing coffee drinking in women as follows: 0-7 oz (0-229 ml), 214 mg/dl; 8-32 oz (230-960 ml), 222 mg/dl; and 33+ oz (961+ ml), 234 mg/dl. This trend was significant at p less than 0.01. Almost all of the difference could be accounted for by an increase in low density lipoprotein cholesterol. Plasma cholesterol was not affected by coffee intake in men or by decaffeinated coffee intake in either sex. The results were unaffected by adjustment for age, obesity index, number of cigarettes smoked per day, ml of alcohol consumed per day, oral contraceptive use, regular exercise, daily intake of saturated, monounsaturated, and polyunsaturated fat, polyunsaturated/saturated fat ratio, use of cream in coffee, and use of sugar in coffee. This study confirms the previously reported significant increase in plasma cholesterol and low density lipoprotein levels with increasing coffee intake in women, and demonstrates that the increase is due largely to elevation of low density lipoprotein cholesterol. The reasons for a differential response to coffee in women and men, reported previously and in this study, deserve further investigation.

In this study, the Eating Disorder Inventory (EDI) was used to determine the incidence of disturbed eating patterns and other characteristics of anorexia nervosa and bulimia among women graduate and medical students. The EDI was given to 219 female graduate students and 132 female medical students by mail questionnaire (61% return rate). Excessive dieting concerns, as measured by the Drive for Thinness subscale, were significantly more common in medical students compared to graduate students (18.7% versus 12.9%; p less than 0.05). The incidence of bulimic eating patterns was also insignificantly higher in the medical students. The prevalence of bulimia estimated from this survey is similar to that reported in undergraduate women, but the estimated prevalence of anorexia nervosa in both medical and graduate students is lower than reported for younger students. Our data suggest that a competitive environment alone does not appear to lead to greater expression of anorexia nervosa and bulimia.

The authors studied the association between postmenopausal estrogen use and mortality from cardiovascular disease, coronary heart disease, cancer, and all causes in a cohort of 1,868 women aged 50-79 years residing in a planned community. After 12 years, the age-adjusted all-cause mortality rate was lower in the 734 postmenopausal estrogen users (14.9/100 women) compared with the 1,134 nonusers (21.5/100 women) (relative risk (RR) = 0.69, 95% confidence interval (Cl) 0.55-0.87). After adjustment for age, systolic blood pressure, social class, fasting plasma cholesterol, fasting plasma glucose, Quetelet index (weight (lbs)/height (in)2 x 100), and cigarette smoking by the Cox model, the relative risk increased to 0.79 (95% Cl 0.62-1.01). Because a postmenopausal estrogen-smoking interaction term was significant (p = 0.025), separate Cox models were run for never, past, and current smokers. In never and current smokers, estrogen was protective for all-cause mortality, with relative risks of 0.67 (95% Cl 0.45-0.99) and 0.62 (95% Cl 0.39-0.98), respectively. However, past smokers were not protected by postmenopausal estrogen use (RR = 1.32, 95% Cl 0.84-2.08). Cause-specific models revealed differences in the association of postmenopausal estrogen use with cardiovascular disease mortality and coronary heart disease mortality that were dependent on smoking status. Postmenopausal estrogen use was strongly protective in current smokers but was associated with increased risk in past smokers. As expected, cancer mortality was increased in smokers. The confidence intervals for the relative risk estimate of postmenopausal estrogen use for cancer mortality in each smoking category included one. Finally, a separate analysis of subsequent three-year mortality in women surviving the first nine years of follow-up revealed reduced death rates only for women using estrogen at both baseline and nine years of follow-up, suggesting both a conservative bias in our data introduced by the large reduction in postmenopausal estrogen use during the study period and the possibility of a stronger protective effect for recent postmenopausal estrogen use.

To assess the effect of dietary calcium intake on risk of hip fracture, a geographically defined caucasian population in southern California was studied prospectively. Between 1973 and 1975, a quantified 24 hour diet recall was obtained by a dietician from 957 men and women aged 50 to 79 years at baseline. Follow-up to 1987 with mortality records and interviews showed 15 men and 18 women with hip fractures. The age-adjusted risk of hip fracture was inversely associated with dietary calcium whether considered as mg per day or as nutrient density (mg per 1000 kcal). No other nutrient was consistently associated with hip fracture in any Cox proportional hazards model that included calcium. The association between calcium and fracture persisted after adjustment for cigarette smoking, alcohol intake, exercise, and obesity. The significant independent inverse association of dietary calcium with subsequent risk of hip fracture (relative risk = 0.6 per 198 mg/1000 kcal) strongly supports the hypothesis that increased dietary calcium intake protects against hip fracture.

The authors studied the association between heart disease and prostatic cancer in Rancho Bernardo, California, from August 1972 to June 1987. During a 14-year follow-up of 1,776 men aged 50-84 years, 100 cases of prostatic cancer were identified, of which 54 were incident. Systolic blood pressure, cigarette smoking, and plasma cholesterol levels in cases did not differ from those in noncases. After adjustment for age and on multivariate analysis, incident cases of prostatic cancer had a nonsignificantly higher frequency of reported heart disease at baseline. History of diabetes was inversely associated with total prostatic cancer (age-adjusted estimated relative risk = 0.2, 90% confidence interval: 0.0-0.8; multivariate-adjusted relative risk = 0.3, 90% confidence interval: 0.1-1.0). The association between heart disease and prostatic cancer is compatible with diagnostic detection bias. The inverse association between diabetes and prostatic cancer is compatible with a cancer-promoting role for endogenous testosterone, the level of which is lower in diabetics, or a risk-reducing effect of antidiabetic diet or drug therapy.

The relationship between plasma cholesterol and seven-year cancer morbidity and mortality was assessed in 4035 residents of Rancho Bernardo , CA, aged 40-89 years. Cancer was the underlying cause of death for 139 persons and occurred in an additional 168 individuals after the 1972-74 cholesterol measurement. The age-adjusted cancer mortality rate per years of experience showed a slightly U-shaped relationship with cholesterol levels in men. For women, little association was seen between cancer mortality and cholesterol levels. Age-adjusted cancer morbidity rates per years of experience, indicated no association for men or women. Mean cholesterol levels did not differ significantly by cancer site. In addition, analysis of cholesterol levels by length of time between cholesterol measurement and cancer occurrence showed no significant trends, suggesting the progression of subclinical cancer did not result in lower cholesterol levels. In summary, in this population no significant association of cholesterol and cancer was seen in men or women.

In the United States women live longer than men, and they have lower death rates at virtually every age and for most causes of death. Similar relationships prevail in most developed nations. The sex differential in mortality has been increasing since the early 1900s , especially for those 15-24 and 55-64 years of age. Since 1970, however, that trend has slowed for persons 45-74, and in 1980 the sex differential was actually lower than in 1970 among those 55-64. Although the female sex advantage in respect to most causes of death has been increasing, the differential for coronary heart disease has recently stabilized; and the lung cancer mortality rate among women is now increasing faster than that among men. Recent statistics for these two important causes of death may indicate that the previous, more favorable trend in women than in men may be reversing in response to changes in lifestyle. Women's health may be improving at a slower rate because they are exposed to more job stresses and other risk factors, such as cigarettes, than before; alternatively, men's health may be improving at a faster rate because they are exercising more, smoking cigarettes less, and following healthier diets in recent decades. Despite their continuing mortality advantage, women experience more illness than men. This may reflect women's greater utilization of medical services, and physicians' diagnostic patterns, as well as women's greater willingness to acknowledge and report illness. Sex differences in illness persist, however, when physical examinations are used for assessment in population-based samples. Women appear to have higher rates of conditions that rarely cause death, for example, rheumatoid arthritis; whereas men tend to have more fatal conditions, such as coronary heart disease. At least two categories of lifestyle characteristics are associated with male-female differences in health: (a) social roles, such as marriage, parenthood, and employment; and (b) behaviors, such as cigarette smoking and Type A behavior. Preliminary evidence indicates that some of these lifestyle characteristics may act synergistically on health. Several aspects of lifestyle thus underlie sex differences in morbidity and mortality. There is also evidence that biological factors influence male/female mortality differences, particularly in infancy and prenatal life. A substantial sex differential remains, however, even after adjusting for numerous lifestyle and biological variables. This is especially true for heart disease mortality.(ABSTRACT TRUNCATED AT 400 WORDS)

Two previous population-based US studies that examined the sex differential for heart disease mortality in diabetics showed an independent effect of diabetes on fatal heart disease only in women. This paper reports sex-specific ischemic heart disease mortality rates and relative risks for a geographically defined population in southern California of men and women aged 40-79 years, 99.5 per cent of whom were followed prospectively for seven years. When the 212 men and 131 women who had diabetes defined by personal history and/or fasting hyperglycemia were compared with 2104 nondiabetics defined by fasting euglycemia and a negative personal and family history of diabetes, the age-adjusted relative risk of death in diabetics attributed to ischemic heart disease was 2.5 for diabetic men and 3.4 for diabetic women. The sex difference increased only minimally after adjustment for heart disease risk factors when the Cox regression model was used: the adjusted risk ratio was 2.4 for diabetic men and 3.5 for diabetic women. In both men and women, diabetes, along with age and plasma cholesterol, was a statistically significant independent predictor of ischemic heart disease mortality. Among diabetics, male sex made a significant independent contribution to the prediction of fatal ischemic heart disease.

To evaluate the validity and implications of using various obesity indices in adjusting or controlling for obesity, correlations were analyzed between six cardiovascular disease risk factors, age, cholesterol, log triglyceride, systolic blood pressure, diastolic blood pressure, and fasting plasma glucose, and weight (W), height (H), and five commonly used obesity indices, W/H, W/H2, 3 square root W/H, -H/3 square root W, and relative weight in a defined population of 4956 men and women. Subjects were residents of Rancho Bernardo, California and were surveyed in 1972-1974. Correlations of weight, height, and the obesity indices were also evaluated with each other. W/H, 3 square root W/H, and -H/3 square root W were highly correlated with weight (correlations = 0.96-0.997), but also correlated with height (correlations = 0.10-0.48). These very high correlations with weight and moderate correlations with height resulted in risk factor correlations with these three indices reflecting weight-risk factor correlations rather than obesity-risk factor correlations. W/H2 and relative weight were not quite so highly correlated with weight (correlations = 0.83-0.89), very highly correlated with each other (correlations = 0.999), and relatively uncorrelated with height (correlations = 0.17-0.01). W/H2 and relative weight risk factor correlations reflected true obesity-risk factor correlations and were significantly greater than risk factor correlations with weight, W/H, 3 square root W/H, and -H/3 square root W. These data strongly support the use of either W/H2 or relative weight for obesity adjustment in cardiovascular disease studies. Use of W/H, 3 square root W/H, or -H/3 square root W may result in underadjustment for obesity.

We examined the association of degree and duration overweight, dietary habits and exercise with non-insulin dependent diabetes mellitus risk in a defined population of 886 men and 1114 women who were aged 50 years and older when examined in 1984-1987. After an oral glucose tolerance test, 142 men and 142 women were classified as diabetic using WHO criteria. Compared to those with appropriate childhood weight, reported underweight as a child significantly increased the rate of diabetes as an adult (RR = 1.3, P less than 0.05). Underweight as a teenager was also associated with an increased rate (RR = 1.3, P less than 0.05). Underweight as a teenager was also associated with an increased rate (RR = 1.4, P less than 0.01). In adults with current body mass indices (weight/height2) greater than 26, the diabetes rate was significantly higher for those underweight as children (RR = 1.7, P less than 0.01). A multivariate logistic regression analysis of adult diet and weight behaviors, adjusting for age and current smoking, found that a weight gain or fluctuation between the ages of 40 and 60 of 10 lbs or more significantly increased the diabetes rate (RR = 1.4, P less than 0.05; RR = 1.7, P less than 0.01). Weight gain between age 18 and the 1984-1987 visit also significantly increased the rate (RR = 1.4 per 17.3 percent, P less than 0.001). Exercise as the only means to control weight was associated with a significantly reduced diabetes rate (RR = 0.05, P less than 0.05).

A specifically designed anonymous questionnaire concerning the use of alcoholic beverages was given to all young people in residence at the San Diego Job Corps Center. Corpsmembers (n = 335), age 16-22 years (mean 18.7 years) completed the questionnaire. There were 67 Caucasians, 65 Blacks, 111 Hispanics, 69 Indochinese, and 23 others. Eighty-five percent of the corpsmembers reported drinking alcohol 1-5 times weekly during the previous six months, and 14% reported average weekend binges of more than 20 drinks. Sixty percent of the adolescent drinkers reported medical, legal, or vocational problems as a result of their drinking. Some striking differences were noted in the drinking habits of the four major subcultural groups represented: 1) Caucasian males began serious drinking at an earlier age than Black, Hispanic or Indochinese youth; 2) more Hispanic youth than others used multiple drugs in addition to marijuana, which was commonly used by all adolescent drinkers; and 3) recently immigrated Indochinese youth indicated that they had turned to alcohol as a means of forgetting past experiences.

It is common knowledge that females tend to live longer than males. In the United States and most other countries, female death rates are lower than male rates for all age groups and most important causes of death. But while they are alive, females' health seems to be worse than males'. Health surveys repeatedly show that females have higher rates of illness, disability days, and health services use. In this article, sex differentials in mortality are presented first, followed by sex differentials in health. Possible explanations for these sex differentials are discussed, and the apparent contradiction--why there is excess female morbidity but excess male mortality--is considered.

Associations between several common health-related practices and a variety of health outcomes have been reported. However, the independent associations between each of these practices and mortality from all causes have not been assessed. In the present report, a multiple logistic analysis of seven potentially health-related practices (individually and in a summary index) and mortality from all causes is conducted, using data from the Human Population Laboratory Study of a random sample of 6928 adults living in Alameda County, California in 1965 and a subsequent nine-year mortality follow-up. Many covariables such as physical health status and socioeconomic status are simultaneously analyzed. The health-related practices examined are: 1) never smoking; 2) regular physical activity; 3) low alcohol consumption; 4) average weight status; 5) sleeping seven to eight hours/night; 6) not skipping breakfast; and 7) not snacking between meals. The analysis reveals that five of the practices are associated with lower mortality from all causes. Neither eating breakfast nor not snacking have significant independent associations with lower mortality. After covariable adjustment, respondents who reported few low-risk practices have a relative risk of 2.3 (p less than 0.001) when compared with those who had many low-risk practices. Mortality risks for possible combinations of health-related practices are discussed.

In a population-based study conducted by the Lipid Research Clinic between 1972 and 1974, the authors investigated the frequency and clustering of five heart disease risk factors--cholesterol, triglycerides, systolic blood pressure, obesity, and cigarette smoking--in 347 diabetic and 2285 euglycemic nondiabetic adults aged 35 to 79 years. Diabetics were more likely than nondiabetics to have high risk factor levels, although excesses for cholesterol and cigarette smoking were not statistically significant. Subjects at or above the 70th or 90th percentiles for one risk factor were more likely to be at or above these percentiles for other risk factors, and this clustering of heart disease risk factors was more common among diabetics than nondiabetics. Excess clustering in diabetics persisted after controlling for obesity and when only cholesterol, blood pressure, and cigarette smoking were analyzed. Clustering was more marked in women than in men. This may explain some of the excess risk of heart disease in female compared to male diabetics, which has been reported by others.

In 1985 nearly 1,700 persons who had exposure to diethylstilbestrol (DES)--520 mothers, 1,079 daughters, and 94 sons--responded to a mailed questionnaire about their general health status. Results were compared with responses to the 1985 National Health Interview Survey and other population-based studies. As with research findings in animals, conditions that suggest possibly impaired immune function--that is, respiratory tract infections, asthma, arthritis, and lupus--were reported more frequently among the persons with DES exposure. Conditions that may involve altered endocrine function were also more frequent among such persons. Given the biased sample, findings from this preliminary survey are seen as guidelines to areas meriting more rigorous research.