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Among men of Japanese ancestry, there is a gradient in the occurrence of coronary heart disease (CHD). It is lowest in Japan, intermediate in Hawaii, and highest in California. This gradient appears not to be completely explained by differences in dietary intake, serum cholesterol, blood pressure or smoking. To test the hypothesis that social and cultural differences may account for the CHD differences between Japan and the United States, 3809 Japanese-Americans in California were classified according to the degree to which they retained a traditional Japanese culture. The most traditional group of Japanese-Americans had a CHD prevalence as low as that observed in Japan. The group that was most acculturated to Western culture had a three- to five-fold excess in CHD prevalence. This difference in CHD rate between most and least acculturated groups could not be accounted for by differences in the major coronary risk factors.

An inverse association between socioeconomic status, as measured by years of education, and blood pressure has been reported in a number of studies. However, two secular trends may have changed the nature of this relation: a higher mean level of education in the population and intervention for high blood pressure in the community. Given that education is the most commonly used indicator of social class and measurement is a critical issue in epidemiologic research, a study was initiated to examine the validity of education for predicting blood pressure among 11,554 examined persons aged 25-74 years from the Second National Health and Nutrition Examination Survey (1976-1980) or the Hispanic Health and Nutrition Examination Survey (1982-1984). In univariate analysis, a consistent, inverse association between education and blood pressure was found for whites and blacks, but not for Mexican Americans. After adjustment for age and body mass, the effect persisted only for systolic blood pressure in whites. The association of education and blood pressure was positive in Mexican-American females. Education was inversely related to hypertensive status in whites and in black females. These findings suggest that information on education may be of little value for identifying populations at risk of high blood pressure, particularly if age and body mass are known. However, information on education may be of considerable value in the design and implementation of appropriate interventions.

Previous studies of Mexican Americans have shown mean diastolic and systolic blood pressures and prevalence rates of hypertension which are either lower than or similar to those for non-Hispanic whites despite the predominance of obesity in Mexican Americans. However, those results are based on restricted samples from California and Texas. Using data from the Second National Health and Nutrition Examination Survey (1976-1980) and the Hispanic Health and Nutrition Examination Survey (1982-1984), the authors examined ethnic differences in blood pressure and hypertension. Regression analyses, stratified by sex, were used to compare mean blood pressures and rates of hypertension in Mexican Americans with those for whites and blacks. Mean diastolic and systolic blood pressures, as well as the prevalence of hypertension, were lower in Mexican Americans than in non-Hispanic whites or in blacks, with whom they shared a remarkably similar risk profile. This effect was unchanged after adjustment for age, body mass index (weight (kg)/height (cm)2 x 100), and education, indicating that blood pressure differences between Mexican Americans, whites, and blacks were not explained by the established correlates of high blood pressure. There are several possible reasons for lower blood pressure in Mexican Americans, including genetic, life-style, and cultural factors.

Studies of the association between type A behavior and coronary heart disease have yielded inconsistent findings. A possible explanation for these inconsistent findings is that type A behavior is simply a marker for other behaviors that are truly related to coronary heart disease. Hostility is one such behavior that has been found in several recent studies to predict coronary heart disease and coronary atherosclerosis; however, several other studies have found null results. In the present study, the predictive power of hostility was tested in a study population of hospitalized men (n = 118) and women (n = 40) scheduled for coronary angiography. Potential coronary risk behaviors were assessed in the angiography patients and they were given the type A Structured Interview. Hostility was measured with the Cook-Medley Hostility Inventory and the Behavior Pattern Hostility Index, a measure of hostility derived from the type A Structured Interview. No significant positive associations were found for either Cook-Medley hostility or behavior pattern hostility and coronary occlusion. This was true whether hostility or coronary occlusion was treated as a dichotomous variable or as a continuous variable. In fact, most of the observed associations were opposite to the predicted direction, although none was statistically significant. Replicating cutpoints of the Cook-Medley Hostility Inventory used in other studies that have reported positive associations with coronary heart disease also yielded null findings. The association between hostility and coronary occlusion was slightly modified by age and sex, but the interaction coefficients were not significant. The sample size yielded adequate statistical power to detect the hypothesized associations, and there was no evidence that selection bias, measurement error, or unexamined confounding accounted for the null findings. These results failed to confirm some earlier reports showing a positive association between hostility and coronary artery disease.

This paper presents an analysis of self-reported stressors and blood pressure in a population of 1,428 San Francisco bus drivers surveyed from 1983 to 1985 as part of an occupational health study. To test the hypothesis of a positive association between psychosocial stressors and hypertension, the authors derived a stressor index from a survey instrument that assessed subjects' appraisal of work-related problems. A logistic regression analysis revealed an unexpected inverse association between the stressor index and hypertension that remained significant after adjustment for 12 potential confounding variables (standardized odds ratio = 0.84, p = 0.038). An analysis restricted to the 1,040 normotensive subjects, with mean blood pressure level as the outcome variable, also yielded inverse findings. To assess whether the results were specific to blood pressure, the authors repeated the multiple logistic analysis for gastrointestinal, respiratory, and musculoskeletal problems. In contrast to the inverse association found for hypertension, highly significant positive associations were found between the stressor index and these health problems. When prevalence of disease was examined by level of stressor score, a significant inverse gradient was observed for hypertension and significant positive gradients were observed for gastrointestinal, respiratory, and musculoskeletal problems (p values less than 0.001). An etiologic implication of these findings is that there may be a direct inverse association between subjective appraisal of stressors and blood pressure. A methodological implication is that subjective appraisal of stressors by persons with heightened blood pressure may be an invalid measure of objective, verifiable stressors.

The link between blood pressure measured at juvenile ages (3-18 years) and subsequent adult ages (30 and 50 years) was investigated in a community-based longitudinal study conducted in the San Francisco Bay Area from 1928 to the present. The original sample of 550 persons decreased 61 percent by age 50 years, leaving only 211 persons in the cohort. Blood pressure was measured annually up to age 18 years and each decade thereafter, providing a unique opportunity to link childhood and adult blood pressures over periods of up to 50 years. Juvenile blood pressure measured from age 6 years onward was a positive predictor of blood pressure at age 30 years. Blood pressure measured at age 50 years was predicted best by juvenile pressures measured at early school age and early puberty. The juvenile-adult blood pressure association was partly explained by controlling for smoking and parental history of cardiovascular disease, but was not explained by controlling for juvenile height or body mass. It was stronger in children from blue collar families. The reported correlations probably represent an underestimation of the true strength of the association because of a greater loss to follow-up among subjects with higher blood pressure and the effects of antihypertensive medication in adulthood.

The association between an a priori measure of social connections and five-year mortality from all causes, cardiovascular diseases (International Classification of Diseases, Eighth Revision (ICD-8) codes 390-458), and ischemic heart disease (ICD-8 codes 410-414) was studied in 13,301 men and women from eastern Finland who were first interviewed in 1972 or 1977. For men, there was a graded association between extent of social connections and mortality. In multivariate models with adjustment for age, smoking, serum cholesterol, mean weighted blood pressure, measures of prevalent illness, and other possible confounders, men who were in the two lowest quintiles of the social connections scale were at increased risk compared with those in the highest quintile (odds ratio (OR)all cause = 1.54, 95% confidence interval (CI) = 1.21-1.95; ORcardiovascular disease = 1.54, 95% CI = 1.11-2.13; ORischemic heart disease = 1.34, 95% CI = 0.94-1.90). No strong or consistent association was found for women. The association for men was modified by levels of blood pressure with the effect of low social connections greater at higher levels of blood pressure. In three separate analyses, there was no evidence for confounding or effect modification due to prevalent illness at baseline.

Type A/B behavior has been studied extensively as a risk factor for coronary heart disease. This study tests the hypothesis that Type A/B behavior is associated with ill health in general. All-cause mortality was examined in the original cohort of 3,154 men aged 39-59 years at baseline in the Western Collaborative Group Study in 1960-1961. Morbidity was examined in a group of 2,365 men aged 61-81 years who were surviving members of the cohort in 1982-1983 and who agreed to fill out a self-administered health status questionnaire. On the basis of these data, a three-level general morbidity index was constructed that included coronary heart disease and a number of other chronic conditions. Type A/B behavior was not significantly associated with all-cause mortality over the 22-year follow-up. However, among men 61-71 years of age, behavior type assessed at the baseline examination 22 years earlier (1960-1961) was positively associated with the morbidity index (p less than 0.001). Furthermore, behavior type and the morbidity index showed a dose-response association; extreme Type A personalities had the highest level of morbidity, while those with the fewest Type A characteristics had the lowest level of morbidity. This general pattern of association was not due to the presence of coronary heart disease or to any other particular disease condition in the morbidity index and did not change when an ordinal logistic regression model was used to control for other baseline risk variables. For the older men (aged 72-81 years), the pattern of association was similar but did not reach statistical significance. Thus, in a group of men over 60, a positive association was found between general morbidity status and Type A/B behavior measured over two decades earlier.

A number of studies have suggested a small to moderate positive relation between blood pressure and blood lead concentration in males (2-4 mmHg/In(microgram/dl]. However, this 1986 study of San Francisco bus drivers suggests larger relations in black males (n = 132) for both systolic pressure (7.5 mmHg/In(microgram/dl] and diastolic pressure (4.7 mmHg/In(microgram/dl] at very low blood lead concentrations (2-21 micrograms/dl). This increase appears to result from negative confounding, particularly after taking into account tobacco use. Relations are even larger in blacks who infrequently use caffeine (16.7 and 10.4 mmHg/In(microgram/dl) for systolic and diastolic pressure, respectively). In contrast, a negative relation between systolic pressure and blood lead concentration (-5.7 mmHg/In(microgram/dl] is suggested in nonblack males (n = 117). These findings indicate that race, lead accumulation, and physiologic effects related to caffeine use (e.g., catecholamine effects) may interact to produce marked differences in effect on blood pressure.

The relationship between social and community ties and mortality was assessed using the 1965 Human Population Laboratory survey of a random sample of 6928 adults in Alameda County, California and a subsequent nine-year mortality follow-up. The findings show that people who lacked social and community ties were more likely to die in the follow-up period than those with more extensive contacts. The age-adjusted relative risks for those most isolated when compared to those with the most social contacts were 2.3 for men and 2.8 for women. The association between social ties and mortality was found to be independent of self-reported physical health status at the time of the 1965 survey, year of death, socioeconomic status, and health practices such as smoking, alcoholic beverage consumption, obesity, physical activity, and utilization of preventive health services as well as a cumulative index of health practices.

This study examines the extent to which a set of 10 demographic, behavioral, and medical risk factors explain black/white differences in hypertension. Data are from a cross-sectional examination of San Francisco transit drivers aged 25-65 years surveyed during 1983-1985 as part of an occupational health study. The inherent restriction of the study population to bus drivers and the further restriction to males in this population (764 blacks and 224 whites) controlled for factors related to occupation and sex. Control of 10 additional potential risk factors, including age, education, body mass index, smoking, and intake of caffeine and alcohol was possible in the analytic phase of the study. The unadjusted prevalence of hypertension (systolic blood pressure greater than or equal to 140 mmHg, diastolic blood pressure greater than or equal to 90 mmHg, or current use of antihypertensive medications) was 36.1 per cent for black males compared with 30.8 per cent for white males. The greatest difference in prevalence was observed for black males aged 55-64 years, for whom the prevalence was 46 per cent higher than for white males the same age. Despite higher rates of hypertension, blacks in all age groups exhibited lower levels of most major risk factors for hypertension. As a result, the independent effect of race on hypertension was increased rather than attenuated when the 10 covariables were taken into account (odds ratio of 1.27 in the unadjusted analysis, increasing to 1.54 in the adjusted, multivariate analysis). That this set of risk factors did not explain the higher rates of hypertension among blacks suggests that racial differences may arise from as yet unrecognized environmental and/or individual factors. The results also indicate that the association between race and blood pressure may have been underestimated in past studies that have relied on unadjusted analyses, in which negative confounding or masking effects of covariables have not been considered.

A cohort of 4653 men of Japanese ancestry living in Hawaii, with traditional Japanese social and cultural lifestyles, were studied for the association of the prevalence and incidence of coronary heart disease (Honolulu Heart Program, 1971-1979). Two of four scales of acculturation were significantly associated with coronary heart disease prevalence independently of 11 other risk factors, but none of the acculturation scales were associated with incidence appeared to be mostly due to the inclusion of fatal cases in the incidence data, although other explanations are possible. Measures of acculturation were also significantly associated wih many of the other coronary heart disease risk factors in such a way that the more traditional Japanese men had lower serum cholesterol and uric acid, were less obese, more physically active, and smoked fewer cigarettes than the more westernized men. A comparison of bivariate and multivariate analyses indicated that some of acculturation scales were indirectly associated with coronary heart disease because of the confounding association with the other risk factors.