/AA762214 NAVAL SUBMARINE MEDICAL RESEARCH LAS GROTON CT CARDIOVASCULAR RISK FACTORS IN SUBMARINERS,(U) 0 V TAPPAN I L W MOONEY ,M J JACEY 1979 ' B A L NSMR 7 llff UNCLASSIFIED FIG 14/5 4 NL L NAT)O~. W.M OF STNDS ,* Oct ~ 1 Cardiovascular risk factors in subm rn D. V.JPPAN, L. W. ?fINDNEY. M. I. AACEV.6W LI)jEYDER/ U Tappa. D V .L W Monne. M4J kacr". sod E H"dgw 5979 Carthovraaculer nsk Woctn is subtnesVo hoonowie s Sub. S"Op 3301- S215. - A utembk 0 - of WaohAMLi hemabsoiogK ad ph) aaoq vun*4es Owa%aidlcatly dhch prpom for thsmaue of am. necaall he cova heart hsase.(CHDI.-. m uleed w 1017 witenmrw. Shiofold ikset hto .aasbhas dtewsaed &u to be Nows the. wemost otWee ptapsome. W of unlar op. theI total level of fat was wihthe ramnp of MOt sarselt) Serm chtolesterol levels. doWtk wookw4.mkowt e. sd iwod pinsure appeed to be the ftcton mo dhww*l inposele for ftheiars; of cardoacua nih in th. wap of subsse Thao sat s~ee- a ap dwecs ielaboobi between lcobol comsewpoa r cafefm dra acardovetsertish. tesm were stnw*cos-etatwms noeed These fctr. combmed wih .w chobsusol lei cont smoieg. newd multae wyt. dew o' coadiunoa as pouesudly awoilabe 0(I) nek LJC*ren. caa*osscuhe nok 11scuor serm cholesterol mhtmy pereomsie mmhuf Alcoho Conumtion bWWo prssst In etrare sludie fte arnosant of lowe seI on activee submatine duty was shown to have tevre bechnwa t~wnesinNaval personnel (Tappan. )amy. Heyder. Ad TauseY 1975. Tappan. Jacey. Heydet. and Harvey 19NO -The prncpsl biochemscal ~~cs of subsuiter We on vounwew bmahnrn we". trends toward incielased meum cholesterol concentratioas and Owmad re ofwilitston gflucose ofer a loaingtl test. 3Bt of these chin wer WW- eMmlitelted directy to yea of submariswm evic sice they occawud in addlit to the chavpe in these seum comilet atruftablet to op ace umm cholesero is a Iro I member of a powq of %clms asweoc ld wth "t~ of cardiorvascular dis (Lev Un iEnw 197); blooe 1973) OWl an exagersled asel response to a CMbh*u load my pmW the eelopment of detest mel IuII ofma-- 1%4). addtonal InVesttlo Of *ANs An related factors seemed warranted for the sum hethy subminer population. 79 l0smil18 U)44 ~ / S202 TAIVAN. UMNEY. JACEY. AND HEYDER In this paper. we bave examined the relationship in 1017 submariners of several hemtatoloW~. biochemical, and physigi vanables that have significance for the prognosis. pevvention. or treatment of disease of apng, with particular reference to factors associated with a rskof coronary hen disease. Though the study was dened to evaluate the effects of submanne duty through a series of re-exammations of the indiviul subjects. this report is concerned with comparisons of the data obtained at the initial examinations of the subjects. We present evidence that there is a measurable risk 01 cariovascul., disease rmiaed to length of submarin duty in addition to the risk attributable to icreasing age. Several factors. including coffee and alcohol consumption and ctgaret smoking. appear to contribute to this risk. METHODS &%D MATERIALS The gmup of 1017 active-duty submariners participating in this study and the extensive series of medical and laboratory, eumanations, perforned on these subjects were described previously (Sawyer with Baker 19r.. Tansey 1974. Tappan et al. 1975, 19M9. The examination program was iitiated to provide backgroud data on the health staws of Mhe geeral ribiirerpopulation and to provide preliminary indications of the effects of livmng withim the closed environments of modern submarines, Of the subjects voluneering for the 00ud. 64 W% were members of the crews of 23 operational submarines, the other ubjects came bo. nam short-based rotation awsstments. All were qualified submariners. Li 7W were enhesed personnet and 14.3% were officers. For our comparative studies, data perthnent to cornay heun disease tCHD) and related risks ware obtained ftm the medical and smhrupom potins, of the two-day serie of tests lpven to each subject and from the biochemical and heasololc segmets of this multiphauic study. The data for time on nuclear patrol were avedable I r-1) from the health records of the men since it is hmnndatory that record he kept at Maie of potential exposure to radiation aboard muclenr submarnes For an estimation of the CI4D risk among the ubjects eumied. the I-l t e w n~b ode of Truett. Cornfield, and Kan-es 11907) based on discsminam Mcto anr alyst of 12-year follow-up data from the Framiunha study of cardiovascular dignme "niec rn wased To calculate the level of cardovascula risk for all of out subjects less than 40 years of #V. a have used the contants in the risk-estimating equation derived by Halerin. Black aeldef. and Vetter (197 1)for thewr lowest age gup ("0-39 yr) Their values for the 461-4 ap 0 f utilized for our subjects agled 40 and above. Included in our risk calculatons am data fr smum cholesterol iingd), systolic blood pressure imaks). relative wet IwinW/edan we*W perhbeightpop x 100.ciprette smoking; 0 - none. I - < 1. 2- I. )3. > I picks'dy). ECO (l - normal. 2 - abnormal. hem-olbin (ill)s. and al (Halpeuieo a l. 1971). We present in Table I the frequecy istt*tlo . means, and btnaddsaosfr a pmip of Wacors asociated directly or "niectlywith cadiovnla risk and fr wo Overal tl. and hemoglobIn weed is the calculations Veoe here ewe NImled is a pisvis pubit in 4Tappmat e al. IM.9 To provide 11 qency data so that the rsade an wae Iherw adcatulom opoultl statistics, the distiutions an shownm in tabular rtete than Igall' hrm The No anid law S203 CARDIOVASCULAR RISK FACTORS TABUK I FeQtENV DiST11VTIONS Of Lowb Ref %Fat Abdomen Ht Wt Skinfold Rel Wt Smokin Systolic Diastobtc Rate coffee Alcohol Risk Rtsk>28 High Ref 3 32. 70 1111 11.2 14.0 12 34 0.7"2 1.44 0 4 148 100 48 96 40 106 0 14 0 64 0.1 6.5 0.1 6.5 POTENTIAL CoaoNARY HXAxT SL 3M ARUIERS 2 3 4 >8 Mean 4897 135 210 1"9170 73 23 7 76 144 233 231 148 104 "4 17 10 49 99 191 236 227 124 57 13 6 9 66 137 150 140 101 67 26 8 9 6 44 16267 248 1473823815 3 330 1.06123 1"9103 66 37 14 40 6 39 149 276 307 159 53 18 7 3 9 9 11 214 285 267 119 21 3 4 4 7 54 10295241 163 4919 3 M469145 110114 55 96120 400 97 421 2L'100 7231 20 301024 349 415 103 47 30 19 8 1 11 27 27 41 197 944 29 135311 19.5 90.1 12.6 40.6 1.01 0.39 113.9 70.2 73.3 <-I 1 31 9 9 5 6 Diusu RisK FACroas 7 8 is SD 5.3 10.4 0.6 16.0 0.14 0.90 8.7 3.2 9.9 4.3 4.3 14.4 1.12 2.14 17.6 3.60 5.09 VaINeS WO mOO1 so Fat - pe ce bodyr Wa.Abdoment - aiemutal cicunirece. cmn. HtW1 - IPoAd- almis. heVIMh(acwtis lght i ms. Shaibi - samiof inacapalar aid tricels sbjefold thickness. ev. Re1 VA - elave melt. iei weWbt? ht V rsq Soks" - W cqretes. picks day. Sysaobc - systok blood pinnat. eaft. iatlc - diastoic pin@to. mtaft. Raw. - pube. biaftituna. Coffe - total coffee. cup~dea' Alcohol - totdaloaho. dilaks/week. Risk - calcuated ignt5 121 yew . @am populbos Malurwa et al, 1971). Ritk>211 calculated %ess 12 yeam. miin 23 year ofa se lderii 4 reference data values for each of the rows are presented in the fi two data columns of the table. The data runge between each panr of reference values is divided into eight equa intervals, with the population count faling %"thineach interval showo in columns I to S. 11e number of suboecs having values belo% and above the reference values are Indiated in columns -c - I and > 3. Fiure I provides an illustration of the data. showing praphcally the distribution of the calculated risk of CHD among the subjects over a 12-year perlid. The blood pressur dama in Table I represent the means of 4 masuremenits each for systlic and diastolic pressures. 2 in the sittg and 2 in the supine position. Pulse rate isa mean value from 2 dretninatoas made at rest in the sialin position. Since total smoking, alcohol intake. and coffee drinking data were recorded for the date of the test and for each peedn O 5-year interval. the WWd fbr these varabls um caclae by: current value * I Ifth of vilue 5 years s * 1l10t of value 10 years qo (Sawyer with Baker 1972). and so fort. Soch a calculation isbased on the work of Coruleld and Mitchell(1909. who con clu dtat touoa the inca- risk of cardiovascular disease associated with smokin disappears raply with tome after smoking is stopped, the risk does not disappear compltely for at least a decadet. Though we named residual elbcis similar to smoking slbta-t for alcohol and -Ne consumption, we found concurrin results when carryover was not included insthe data. To icueciparee smoking in the calculation of CUD risk. only th mu of soking at the11 tim of the eamaed lon was, used to coafor to the ,1sk-eeton p redtue emp1flod (Trueft at al. 1967; Halperin st Wi.1971). -414. 520 TAPPAN. MOONEY. JACIEY. AND HEYDER 400 a iL 200 0 z <.I Ft. I Pfrmfty .9 I~s 2.5 4.1 5. 7 % RISK OF CMO INCIDENT Pawu psm W Akhbouo sock of th mamm of gmWa body of the 00mu of my advidua. ths urn soaa ofm C D laddar .l" >6.5 12ym W 1017 Mom gives a wmewhas dilii W wm e &=M mom 6 vadami estima. The comkosm coofficam of omii" woi~k. which boned in the calcidm of risk. aphat the otha estima of body bulk or himwem &s097 (mi pueu 60. 0i.= (vs. abdoin cIc - dkmncs. -09M (vs. puismI ludeM. aid OJI? (vs. mm of Wmtlia). Al vordMlulm um s- Mplat p < 0.001 (Seoor gd Cochim 1967). Trake2 howi -orvubdomofdthe kmad poe rb& hc od of smmmdwishd apmat qp. sat iIm ial Urn. m vie Urns, ad Urn exposed to dnsd wbsmme e'mosus.Correlula -eopm smuhd ioav~wso I ---*- tis. pum pw. adid rscetimecud-for apeftd. Ecep fbr he amsip~ca aur doh- wtW slbfr BCE abwrwldsa ad I7m Mood p.m iuhlho cmosore okalid tWel u- thaim tCARDIOVASCULAR S203 RISK FACTORS TAUS 2 Cottwttviof's or Pbrp~rimt CowwASY HEART DS&Aw Rm FACTORS WIne1 AGE. St.1MAR11111 QLAAIPICAIIO Tim. ANiD Marw~nv SEUVCs Timc iN Suussarn~Es Age 4i21 Factor Age Subm Nuke Serv 43) (4) (5) 0.951' - - 0a.166t 0.099 191e 0co. 0.07e 0.I g 02 0.199 0 01t0.0 F10 cgwowhmo0.1481 017 e 0.00 cv 0on5 o uban qaldkto Systlic Distlc.24 R14.2 0346t 05635f - R13.20 0.3to 0. 0 r9htw Ak-th old 1eut1,ph0. 0eccy. and 001 . Sb0 0antt 1 0-ose fct patrol After 0ac01a th2t0e.ssaict - 0.02,0.2 bath4 00 f 0.111fo theefec14 coeer05." R13.2 at 0P2 0.ahye co2el4e 0.061cn~ s0b0rin 0. 1'son 0.07 se.0d tao.SOOc w I ecrrekatioors. Totd evyFhroriskcount we&n avalemotese th e standea . d mrm Co -n eutropiA lymphocawes gNueallydecws a relave wenww relati-eelymphocyte cMmwemug, Swhite cefi counts.ldrmwrbe noted thattcmimplatio.swill I d o sows compa3reid or s2nt bctrende tofmbe nepti ams the3. -s p 2* poqpualifiato ofcoe datmcole positi evelwithe effcts o'ure. th mst andlrs ai.eesterol tbodroten.ol. of stp (Mdepoar andi glcose1967)a icholegeo cob omm two Varilmbit levelohed eambe correao apingivel ith the mOuthn apin pice. ursbmaad aa. Ot her nsocw hadogahb old coelte countot serv sId wmit phehame tend cemintr ceariak Tahkl toeidirtes coreionse'O awlcted ulis fptnilak.rale isoe nTk2 atilcnltmcluain nuA w' riskthe br pwerel efe-sofi*a corctO actua ai1967 andortedsa ale dimsth and 46.llii thm ee swlutl at P < 0se05eamSodoe e i fl.-rw tmw iutbetw onl lash mabier well it mappdaen wtheda om seud erimyted pulishe sties Ind nii toa etohs nlwivctsorltdiiiatywt -ccis woo S20 CARDIOVASCULAR RISK FACTORS TANA I of PoTWNT1AI CoaoNmav HaAny Dis&ASE RIS FAcToRs Wit" Aot. SvemAeuir QvtivavArTom Time, AN4D MILITARY Seavica Timt tIN SIJRMARINE Cowwt.ATtois Fa rAgV 1I 21 Subs, Nuke Serv 411 t44 451 Systohe Hb Rel wt FCG Risk Dowstob Rate coffee 0.148f 0.417t -0015 -0.0'"0 0 221# -0.0A., 0.4.%t 0-274 0VR 0993 0.5"'1 ous 0-166t 0.2w9 0.000 0.043 0.203' -002.6 0 424t 0.231t 038 0.4901 o*f 4 0063* 0 199f 0.055 -0029 0-127t -0.013 0.304* 0.1811 0.032 0.31.1' Alcohol 0 106$ 0 122f 0.013 A..e Smoking (liof - R13,20 o.sIt 0.191 t 0.0731 0.301t 0.0659 00i11 0.023 -0.029 -0.002 0.237f 0.044 -0.043 0.032 0.445' 0.U$ 0.284t 0.01M 0. IOP -0.027 0..544 0.053 0. 120' 0.061 It14.2 1115.2 -- 0.021 0.033 0.0751 -0.002 0.007 0.013 0.07311 0.043 -0.026 0.023 -0.0541 0. 14t 0.029 0-061$ O.060 0.009 0.021 0O0l 0.078# 0.04 0. 130 0.0759 'dabae we covewte me lwfkwts *Fw nsk Owton. weeTakl I kxoews. Aw - yeen. Sub. yta %vin e uobumawnuabton. Nub. - yea om acb -1u--- rn%Choi - chole~eni. wod masr wtm er'%- wan' 4 nmbtwy senice. lNb - hemogkwts. '4l. FC - elcrcru msktae. *mi': - coneitwiba of variable 0001U). tr 001. If 005 a couina I ad wbowmO 01e ato -soe for ap (2). apM-At rue 4f 'ubMOMI qaaltkatWG Or tne OIL Racetr Petro. OfWerMIOV1l Of the tifOct of age lSnecfcor andl Cochran 1967i. cholesterol levels. ECG aboonnallbes. OWd total risk levtls had a hoome correlation agamst vabtmarine time than amafht the oduer two variables. Other rik faWons ha a hbghe coffebtion afamst total service tise Tattle ) ondmcates coftelatgoms of the h-9 Lokgy and chemstry variables masured aginst the seleced hst of poseiwin risk vanables preented in Table 2. Partia correlation callations iSneilecar and Cochran 1907) were used to correct for the effects of both RV wtu so' nai v servocc tuwn these data, only those corvelatioes that were signifiant at P < 005 we shown. It vs apparent from the dfta that the "ruwcyle elements. hmOcw and hemoglobla. as well ss the total leucocytes. meutrophils. and lymphocytes correlated sigilcanly with seveia of the potefflsi mk factor. Totld erythrocyte Counts wer no avalble anwim thewe data Since ielatisw or percen lymphocytes, generally decrease as neutumphis increase in standard Nfem Inwtal u e cell counts. dtshould be noted that correlatimonsorelative lymphocyte cout spnt the rtsk acosnded tobhe neptive data noshwul compaedto the slcam postewcorrlions recovded for calculaedtotalacllmasher (Table31. For the most part. 2-h postprundial glucose data cornelatd positively wAt risk factors Fasting and postprandia ghcase as wrel as urk said. cholestrol totl proen I lh@I, a. and two oftheeatymes correlaI neptivey withthe mnt o of-fee GoompuOn". Variations oftuc acid. cows. hesoglobia. tow Ilucy"e Count. setuspho' hate e~ort I wam. lowa potts. an allsk phI Incnetwt hs tede to oIu si cacldriak. Table 4 shos One memos kw woud rik aad actual or posile rbsk famr foth *a ect in Av*-yin qp pump between ao13 led 0;prbn , WAO4M*0 wit a seven 1 Tbea esioudy pubishe IsIuItIm m- tde" inskMA sreu 'uate Am a, MIX6 TAPPAN. MOONEY. JACEY. AND HEYDER TAMLE3 Coanio or HaMAIoWOG AN'D SERVM CONSTITVEITS WiT14 POTENTIA1. COWoe&XV HEART DISASE RIsK FAcTooR OIcTaD mwi Aoa AND SvMauiNS QtJALJCAIIOI TowE HCT smoking alcohol systolic diastolic 211?? coffee 0,137t 0.0116t 0.06119 0.171$t 01811p 0. 129f 0.1W~ 0.129$ rate chol rel W1 risk systolic diastolic rate chol rel %V CA alcohol smoking diastoki 0.0811 systolic 0. 116t rate chol rei art 0.1w9 0.107t 0. 49 diastoki rate Chi P110 risk 0.0371: Cofse alcolhol systolic role smok.ing 0.2)9 0.019 0.110 lt 0.0744 0.221t TLMp smoking 0. 179t Coffee 0.004t 0.0744 0.08S 0.IlI, 0.132t 0.076# 0. 141t 0. tos" coffee 0182f alcohol 0.071II chot 0.1Is" risk 0,254$ DUN smoking -0.110 alcobol -0.014 dm1l 0.0964 risk 0.121f UA Coffe -0.1lot dial 06$ ref wt 0.079 risk 0.2Wt CHOL coffee -0.196t 0.295t 0.126' 0.0739 0-197f 0.0159 0.077f GLUC diastolic rat rel wo utah -0-0119 caffe diffstolic 0.0699 iPI smoking -0-116t coffee -0.0711 &[Cohol 0.01 systolic 0.069 diastolic 0.132t 0.136t 0.262f 0.091t rate chol coffee HS WICS smokmn cog"e alcohol rue C101 tt~h NEUT smoking 0. 1l4 0.0799 0. 109$ 0.0731 0.0769 0.122, ris ALON smokig -00110 systolic 0.0726 diastolic 0. 113t rat -0.0460 GLOB smoking -0.01 Coffee 0.10111 alcohol 0.097S diastolic 0.0731 rat 0. 1731P Choi 0.149t rU art W 0.074 AIO smoking 0.01 TBIL smoking 0.337t CO&e 0.0799 LDH saiokaq alcohol rate rel wt 0.0731 0.01)9 0.11 5t 0.172t SGO coffee akbo diastoli -0.0739 0.135t 0.101$i 0.195' 0.149' 0.194t rate chol rel wt SpOGR alcohol, -0. 1034 AK coffee -0.0711 rat 00 C1101 ref art 0.343t 0.0111 0.089* 0.085:1 0. 156't 0.436t %fohat, O iye gM. Pa rf hF of T"i I am 2 #894um: Ila bte ";iU US - hasglbla; WKC - whilee il l. NIUT - muecpbb: TUWF - fina Wo eborya OLIJC - belg #=ss.m* -hW CA - amlom; PROS fterpmc pbw phemvs: SUN - orea Walrps; UA a rkc odd; CHOL * chalesterel TPR *W pmeW.s ALON - athomtia; GLOB - globelia; AIO - aftemialgh~bea ratio; TOIL I oWah~iulb; ALKF - aloln (M- pbempliese;. LON in *ol heir ov'pui: 110OT u*~ mn~m; SIP _viy wdl_ tr - 0.01. p 4 "L p - &a S207 CARDIOVASCULAR RISK FACTORS ConNAav W&ART tau"m DIusKAS RiSK AND TABUK 4 RiSK F~cToas Pta AOL CArwOms~t a Sew 111 %Oaka us" *8 VA i- t 39.41 4) 39 41 5 29 1 104 99is 004 0 e 44 'U0 so 04 lik.1I %%wm Cowl 1., 62 9, M54 104 1b 909? 1' 2:.,' &l 9 Toe 299:104 '44' HiO w SvuAiraw~a S)V1i, 19 199 19 16 il q Em 0X 11V0 OW ft'' am *1 0 a4111 discussed with respect to subjects ag. T7hough the small number of sub*ect inthe oldest age group appeared in some cases to disrupt the agerclated trends. vanous generalizatlion. may be made concerning the changing levels of the nsk factors as the population aged. Cholesterol coficentrations and relative weight that appear in the nisk-estsmating equation (Halpern et al. 1971) showed unustakable tendencies to increase with aW. and they thereby increased the overall calculated levels of risk. Amouint Of cigarette smoking increased among the younger subjts for the first 15 t 5yewrs of service. and then began to decrease among the older subject. On the other hand. hemogk'bsn concentrations. systolic blood guessures. and ECG abnormalities twhich ame actually non-numenc in nature) were not age-dependent, according to this evaluation. Both total alcohol consumnpto and coffee drinking dlearly incileased with subariners' age. Several aspects of the data for these one thousand appandy healthy amn aged 16-8 are worthy of wrous conlsideration. Fromt the pilefims investigatio of bwochemical fladig im these subjects. it was concluded thlet most of the dota fell within rmap comsidered morseel (Tappan et al.- 1973). aned it is ano strprisin dthat with reme exceptions, the samte obsoedoatio cmn be madek concerning the factors analyzed inm repoi . It is importaint. however. to PO out tat staitcally, oL, rarges for biochemical or physiologic variables for populations in thes country do not necessarily speif the conditions conducive to optimal healt, antd that mndrvdtals areavarying degre of risk for serious healt problems that requmw dentificataon anld amelioration. An evaluation of the extaet of existing risks prsdes a loped foundation for insttuting programt desiped to pirevent or bas such risks. The reltive weipt or ftness, of the sulject this study was evaluated no only because of the agkace of the reave wuighit ofan individual! to CHD risk (Tmein let d. 1967. Ha0psim tA W. 197 1. Kann1. Caaue. McNamem McKee. aned Peinluib 1972). but dalobecmaeoftOw ineloruanc to the submarin Navry ofe answer to the querstion of oWtsh habits land tie that deop aboardm sb -' inrnedring patrolledto weight to perational per nl Accate kdorionm re g the degre of lha nes to the su-e is als i imPort11nto relation- to the geea level of decondtioaeft of physical fitness experlenced by saubiera dwrin deplo) we t is ala of con id IrIagle s 0nce is detm1ning whethe the Woo of Use spent on1 nemega p agl ismalcrtcal to the accondi of occupedwtllo f In this uniqe voctin the t1esa elaio o umr 1aiduty. The mods at Vvin aboard 11~ e tho mend. to paomote minimal phyical activity end the coeamptieni of - I S2OS TAPPAN, MOONEY. JACEY. AND HEYDER generous diets, either of which promotes weight increases. may serve as models for the study of the effects of living habits that predominate in the American population. Since there is ite controversy over the fact that' the real culprit to good health ii. not lota body weingh. but relative or percent fat" Wnght and Wilmore 19741. many mthodsi have been proposed to estimaite the degree of fatness or obesty in human subjets The indirect estimate of percent body fat calculated from our data by the procedure of Wright and Wilmore 11974) yieledt.mean value of 19. 5 .8%~ (sw) (at for the submariners. We chose the simpler of the methods described by these authors. which employ% weight and abdominal circumference and correlates highly (P - 0.99) with measured data *tied by underwater weighing methods, to, avoid error in the use of their alternate procedure using skinfold data because of differences in the calipers used. Results for a similar population indicated 16.5 -6. 2' body fat for .197 randoimly selected marine%with an average age of 28,7 years (Wright and Wilmore 1974). A survey also showed 14 3.14.6.15.). 15.5. and 18.7% fat for civilian males. 23.1%~ for an Air Forve population, and 12 5, 17.4. and V0 5'* in Army personnel, all forages in the range of the men in our study iWright and Wilmnore 1974). Though the spread of available data indicates the possibility of considerable experimental error, we concluded that the relative faitsii of the submariners tended toward high normal ranges but did nam greatly exceed that of may similar groups of healthy young men. Among the other indexes of gieneral body conformation, the sum of skinfold measurements from the upper arm 4tricpsL) and subicapular onfrascapularl re~pon% indied a considerabl excess of skinfold thickness in the subjects of this study compared to other population groups. While the overall mean for this group of submariners was 4.0 t 16 cm. a Aimilar mean for a probability sample of men aped IS- 79. representing the non-istotutionalired population of the United States tSioudt. Damon. McFarland. and Robert%1973). has been reported tobhe 18cm. with means of 2.4to )-0cm for the age categories between 18 and.44 years. All groups to men. including foreign and domestic populations. Army personnel. and former Naval aviators. whose data are summarized in the Nattial Center for Health Statistics (NCHSi Report iStouditetal 1973) have considerably smaller %kinfold measurements than the subjets of the current study. Means or median values rane from 1.1o3.4 cm for the various groups. Researchers involved in makig skinfold measurements emlplasize that differences nvariably arise from varoiats in the technique of different investigators and the use of different calipers iMeyer 1973. Stoud et A. 1973v A comparion of skinfold data for 46 men masured by three different types of caliper showed mean values, of 1.69. 1.84. and 2.19 cm for mnfa scapular skinfolds, and 1.07. 1.13. and 1.27 cm for triceps skinfolds using the Harpenden. Iang. and Minnesota calipers, respectively (Soude et al. 1973). This V4* variability among istruinents does no seemi sufficient to ezplai the discrepancy between the data of the porsent study and those reported earlier. especially since we employed L.ange calipers. which prod-ce mid-rage values. From such consideration, we concluded that submariners fre- quently have skafold thicknesses in excess of those of men of comparable groups. In a fu~he comiparison of the skinfold data reported for the NCHS survey (Stoui et al. ".7)with similar amow rouin frm our study, our means went 1.90 ± 0.512and 2.16 ± 0.9" cm for triceps and sulscapulor skinfolds. respectively, while mneans for the HCHS survey were 1.1 andl 1.4 cm. Hencs the two measuremens sem to account about equally for the increae in the sum of sifold thickness reporte for these sub*t. In cftrenrace among; our sabjects equal to 90.1 :z 10.4 cma and With the mavi n the m valae for the me of the NCN3 varvey 815.9 cm. with m0of the population falliag bete 72.1 and 10.0cinfSkmiltet al. 1973h. theis no remn o conclude that there was a sigalkcant dillbeenc betwee subiarinen and American - for this measur of body sia. CARDIOVASCULAR RISK FACTORS S20 The ponderal index establishes a leanness-stockiness scale and is considered by some investigators to be the singlle best measure of body build (Meyer 1973; Stoudt el al. 1973). The mean index value for men of the United States in 1960- 3962 was 12.40. ra.tq from 12.67 for men Ill-24 years to 12.32 for 35-44 yeams (Staudt el al. 1973). In the present study the mean of 12.6 2 0.6 indicated no remarkable difference, according to this criterion. between submariners and other American men. Since the values for this index fall within a very narrow rage. the mean value of 12.73 2 0.63 found for U.-S.- Army men (Staudt et al. 3973) may indicate a slightly pster degree of leanness in Army subjects compared to submariners. (Note that the index increases as relative fatness decrease.) To consider the contributions of the various factors to the risk 01 cardiovascular disease an assumption was mae concerning the applicability of the analysis of risk to our subjects according to the multivariate logistic procedure. The orignal model of Truett et al. (1967). based on data for seven parameters measured for the subjects 01 the Framingham study, was later modified by Cornfield and Mitchell (3969) to include only five variables.- The procedure was further refined by Halperin et al. (1971). who used a maximum likelihood method for arriving at parameter constants and again used seven variables to define risk. The generality of the latter approach was verified by Brand. Rosenman. Scholti. and Friedman (1976) for application to cardiovascular disease incidence data collected over Sit years in dhe Western Collaborative Group Study In that study, correlation coefficients of0012-0.19 were found betueen predicted and actual occurrence 01 cardiovascular disease. Though high correlations ir w 0,9411 were obtained for our data between the five-variable and the seven-variable analyses, the maximumi likelihood constants of Halperin et al. (1971 I were used to obtain the nisk estiates reported here because of the confirmation (Brand et al.- 19761 of the validity of this approach. The 'alue of the procedure used here was emphasized by Gordon and Kennel 119711 and by Kennel 1197,6 who considered this the method that practicing physicians shoul use to evaluate risk levels in their patients realistically. One rather profound alteration in the design of the mutivarsate analysis of risk was required to accommodate part of the data front our study. Since the risk of cardiovascular incident was collected fro the Framinomn subjects for population Voups agled 30-39.40-49. and older. it was necessy to use the values for the lowest age group (30-39) to evaluate our subjects aged 19- 30 and 30- 39. The equation coefficients for ales 40-49 were used for calculations made for subjects over 40. Since the mean age for the subjects was 29.4 year. an overappeoximaition of risk seems to have been made for about half of the subject. When calculationswr performedforthe olderhalf01thesubjecs 2.0 yea or above, for w ond constants apply with reasonabl accuracy, the meom risk was 2.14 1 5.09 per 100 owv 32 years compared to an approximat risk of11.12 * 3.4Gfortheploupaaa whole. It may be eenflomthdateaflble 4dspie tu aproaleoveremationmof riskfor theyoungermeamr ode pp a steady increase in risk occurrd for the subjects during thlr caeer of submar-eduty. Wth our present level of infbomation, we can only determine within a wide mearnof uncertainty whether die me experlenced a cardovascular risk dilhret lhum doot 0 cmrble poultines, in other occupations. Lmrg standard deviatons in all of the etimaes po ted here idicate hirty serious risks for a few Indvidual, which by this model may minich 15-30 chances per 100 over the 32year risk period. Despte ewpao1s1- oveemo a end my psycholoocad amqe thmightbe ihed.dOa poe"a formodlylag risk (Gordoinsand Kassed 1971; Proelchr and Lancaster I97)-. Kamd.l INJOrtboi. and Cu"t IM74) n examinations and risk eWiate (smc a aioe perfbrmed he) po ely Vurc b a populaton a you" and vilorou, as -ubArwinesevi meers. S210 TAPPAN. MOONEY. JACEY. AND HEYDER The data preented in Table 2, which relate known and possible risk lactors to length of time since qualiiation for subaine service. number of Year aboard nuclear submarines, and total time of military service. lfumsh partial answers to the question of whethe duty done sWet in the Closed eaviroameat of modern submarines is primarily responsible for amy health-relaed effects among the subjects. The data for lengh of exposure to closed submarine environments are only pertanem to time spent aboar nuclear submarines, since similar infortation concerning time spent on diesel submarines Was not available Also diesel submaries operate by periodically adding fresh air to the submarine enviaronment and arm almost obsolete in the U S. Navy.Table .1indicates that for most of the known or possible cardiovascular risk factors. theme is a higher Correlation With total military serice time than with tume since Qualification for submarine serice. In general, the correlation for tume spent on submerged Patrols was lower. The strong, correlations of the risk factors with age, however. suses the imnportance of examining correlations that have been corrected for age (Siiwecor and Cochran 19C7). With a few, notabl exceptions, such data, presented in the last three columns of Table 2. indicate that the risk factors have the highest correlatioris with total militar) service time. Submerged patrol tame had the lowest correlations, with relationship to submiarine time generally intermediate. The exceptions to these generalizationsneed special consideration. Particularly prominent among the age-correctedl correlations of the risk factors is the apparenty Significant (P < 0-051 correlation of cholesterol level with time sice qualification for submarine service, This relationship, reported earlier (Tppan et al. 1979). appemn stronger than that to military servce time, and the increased association cannot be directly related to time spent on submerged patrols. Total calculated risk. party but niot entirely because of its dependence on cholesterol level, also seems to correlste most highly with length of submarine service. If these relationships to subarine time are irerdled by other studies, various stressons in the Wie of submariners, such as the abteation in routine between on-boad submarine duty and ashore *recovcry' periods or the unique workrest schedules on patrol, arid the specific diet and activity patterns. may be shown to a, S P t these effects sauiflcandly. Despite the sonificant correlatons of serum cholesterol levels and risk against submn time demonstrated hbae and in our other paper (this Supplemienti (Tappan et a&.19IM. we wish to sound a note of cautio in interpreting the data because of the method used to choose subects for the study (Sawyer with Baker 1972; Tansey 1974). Although the subjects included submariners of various s. lengths of service. and occupational specialties, it was so proved that these men represent an unbiased cross-secton of submarine service peron. A split-samiple correlation analysis performed as a check on the sipilcuue of the incrent in age-correed cardiovascular risk with length of submarin sevice however, helped confirm the reliability of the data. For the verdication tem. t population was divided accordingl to a random selection procedure a complete set of correlation analyse was peeforad for each of the two subgroups. The correlation agast submarmn timie, afte correcton for the influence of age. for the two subpopulation containin 49.7 and 50.3% of the avalable subjects were 0.2192 mad 0.222. respectively. The sipioficancer ratio of 0.412 clearly ikndiae tha the to gmpscasinosbe consideredto have bendran f op seart poptilaiotm(Snsdewo mod Cochra 1967). The dea ilhaewnsed in Table 3 weww derived to deternm whether my insopt might be gamsed an* the etilgy of caudlovasadar risk born the commonly wmmeed serm chemistry or hematrolg walabies. Puial corarLn Orcion for de comI Ionm of alp and subamin service we reeome for die dea t 10 cownerebhtOnshis betwee the ris ONe, ad laboratorv #I fmigh be independent of te expwelmesl sitio. Tbq W CARDIOVASCULAR RISK FACTORS S211 correlat,ons, with possible statistical sgnificance are shown in the table, Only the most outstanding will be discussed. Others that seem unimportant now may eventually become imparThe positive correlations of the risk factors with hemoglobin and hemnatocnt levels apparenitly derived in I&W pan from the fact that ciarette smoking increases hemnatocrit or hemoglobin levels through the relative anoxia produced by carbon monoxide and other noxious agents iFroelicher and Lancaster 1973). The cattioxyhemoglotmn levels in submariners and the relative concentration of this hemoglobin derivative in smokers and non-smoker mna closed submarine environment have recently been described b) Bonds. Very. and Schaefer 41978) From a nationial survey in~.olving 29.000 Mood donors living in urban. suburbian. and rural communities of the United States, a strong correlation has been reported bertween blood levels of catoyhemoglobin and total blood hemoglobin concentrationst Tobacco smoking was the tingle most important factor for increased cartioxyhemoglobii saturations observed iStuart. Baretta, Platte. Stuart. Kaibfeisch. Vain Yserloo, and Rimm 1974)11Th correlation datm presented in Table 3 also suuest that leucocytei and neutropluls ma) tie related to CHD risk through extent of cigarette smoking. T'he possibility of inhibition of chemoictaxis of leucoc)tes by the components of cigartt smoke- particularti by the various aldehydes. has been suggested by Eichel and Shahock 419691 and by Bridges. Kraal. Huang. and Chancellor 1977a; Bridge%. Kraal. Huang. and Chancellor 197"b It should also be noted that each of the seum proteins measured correlated negatinely with the extent of cigarette smoking In addition to its close relationiship to cholesterol level, total risk also correlated highl in the submariners with ,.arious chemical components of the serum, including inorganic phosphate, urea nitrogen. uric acid, and alkaline phosphatase Among other relationships show&n in Table I that should be considered ame the sigificant correlaions of blood presure, pulse rate. cholesterol, and relative weight with hemoglobin aid hematocni levels These correlations add confirmatory evidence that justifies the inclu%ionof hemoglobin in the calculation of CHD risk fTruelt ei al 1967. Halperin et al. 1971). Similarly, the positive association of blood pressure. palse rate, cholesterol, and relative weigh: with postprandial glucose levels supports the established associaiti of diabetes with CHDnrik iGordon andKannet 1971.Kanneet aI 1974). Though none of the subjects of this vtud . to our know ledge, was diabetic, a measuii'l prediabetic symptomnatology was detected in the data iTappan et al 19179. this Supplement). In most cases where risk was apparetly associated with serum chemistry variables, i.e.. with inorganic phosphate. urea nitrogen, uric acid, or alkaline phosphatase. the cholesterol level appeared to be the most closely related of the established risk fators. At this point. however, there s% no reason to think that changes in cholesterol level arm responsible for the fluctuatioins of other serum components, Blood pressure and heart rate. according to these data, are associated positively with serum protein levels. particularly total prtin and globulin These indicators of increased work load on the circulatory system, including the slgh relative hemoconceitration. apparently reflect as well as contribute to the long-term accumulation of CHD risk in the wb~cts of this study, The negative correlaion of urinary specdlc gravity with alcohol consuimption may imply a siht real dysfianction or perhaps A Icreme in thu-st as a delayed aftereffect leading to increased water loading and excretion. Though it is obvmos that the variables used to estimate risk should correlat highl with risk. calculatioas were mae to evaluat the relatve contrliatlon of the individual thectorii to overall cardwoveacular disese risk in submarines. Conuaousan for these and other variables against ris we: smokting 0.272: alcoho corautpim 0.003t. coffee 0.266. I @II 0.2)6';puls rat 0. l064. rbl PIc 0.037: systolk blood ptessur 0.09St; diasto pMe 4 S2l2 TAPPAN. MOONEY, JACEY. AND HEYDER weight 0.253f. and cholesterol 0.5' 0' - P <0.001. S - P -. 0.0i1. These data leave little doutab that cigarette smoking, blood pressure. relative weight, and serum cholesterol levels make estremel) important contributions to the risk of cardiovascular disease in soubmanners. as is true for the population an general (tidam 1969; Kannel and Dawber 1972). The above correlations and those shown in Table 4 wmnest that total alcohol consumption is somewhat less closely associated with factort directly of indirectly related to CHD risk than is total coffee consumption. Because of alcohol's potential for damage to the liver and other orgas however. it is expected that alcottol intake will be at least weakly associated with serum levels of SGOT and LDH uI).mm and King 1965, bieber 19751 and possibly with erythroc~yte counts and serum protein levels Despite a significant association between coffee consumption andl CHD risk, the relationship beWeen the two %anablsappears to be complex. Although faiting and postprandial glucose, uric acid, cholesterol, and total protein, as well as the enzyaws ALKP a&d SOOT. exhibit negative correlations with coffee intake, these factors generally correlate positively with total risk levels. It appears possible that two different physsoocal effects of coffee consumption may be reflected hy the data, First, the diuretic effect of large amounts of the beverage may exert at least a small influence on various serum components because of increae excretion rates. Second. the stimulant Mfect on the central nr o'us and cardiovascular s)ystems of the alkaloid components of coffee is probably even more intimately associated with CHO ris in these personnel. Either because persons who are emotionally more tense tend to drink morm coffee or because coffee consumption leads to increaseid tension, coffee drinking may be associated with CHI) risk in the petuliar occupatiorial circumstanices of the subjects in this study. The susceptijbilty it, CHD of inlivduals who are emotionally stresserd, who feel a strong sense of urgency. or who arm hahtuall) over-conipetitive or hostile isfairlyi well estaklished 4Friedman 1969. Rosenmnan. Brand. Jenkins. Friedman. Straus. and Wurm 197!i. Jenkins. Zyzanski. and Itoseaman 1976. Glass 19711 The term type A pemrsoaitty has been used by Friedman and Roseniman i l"9. 19741 to descrtbe such indivdua- Though st to not within the scope of this report to consider the psychological makeup of these -ubjeci.s. there is considerable evidence to indicate that highly moiated pernel .olunteer for submarine duty iWeybrvw 19,71) Several of out sutjecs may therefore he predicted to fall into the type A category. Aucording to Table 4. the level of alcohol use increases hy a factor o about 1.5between the ,ourqiest and the oldest groups of suAetis, while cigarette smoking is heavier for men between the agsn of .8 and V8 than for younger subjects and decreases again after aboust the age of 40 M~ean coffee consumption increases four. or fivefold for subjects between their 19th and 48th years Although the data are not adequate to establish a causative relationtship between either alcobol or coffee consuaption and risk of cardiovascular disease, theme is an association with these habis that cam only be attributed partly to their comrlations with age. Table .1 indics sigimflcant correlations of these habits with length of service even after the partial correlation effects of age have been eliminated- Regular alcohol consumption, even in what may be considered moderate amounts. has been extensively documented as a potential contribuwo to heart disease i~ing. Tillmans. and Ideka 1975. Guninar. Demakis. Rahimtooia. Sinno. and Tabin 1975. Regan. Ettinger. Oldwiiel. and Haider 1975. Talbot 1975). No absolute evaluasion of the comparative nisk for CHID in these subjects can be mde with other groups because of the methodologtc differences discussed earlier, the relatively small number of subjecs in the older age groups, and die variey of methods used by various authors for reporting incidence of disease. Nevertheless. it is instruactive to compete the apparent risks, as shownt in Table 4. with the frequency of cardkvascular dissaseis) observed in othe Studies CARDIOVASCUL AR RISK FACTORSS23 From the tab"e of pretbctive n~k% denved from data of the Framngham stud) 4kannel 11,141. it nu) he deterined that for pcr'on' Aliho% chleiterol valuc% are 210 mgdl. vhmfte %s%lobi bloodl prc%'urE ame 1.0 mmHg. aho %amoke. and Oho eithibit neither giucosir intoler Ance nor left heArt %cntncIeclctrocardifgrAm ahuotralatit. the e~pected prxuhahulittKe of de~IopunS hean diheaa within 11)car% air 0 9 I) at ageW l.1 S 100lat 40. and 4 K 1010 for Dowt~rie fw he re aerw odeinte nd%utpA:ed oronar%hearl disae chi men i )Car%, 2 M Alt)IS- 49 %cam~2 01M at 40-44 )Cam~ and to 101)at 41-49 )Cot% of Age i~ordlon and (,armt 190P~ In the %%ctcrnCollabor-ati~c (iroup Stud). NWz)ear occurtence late%of CHD. including Angina pecitonm. mso.srdal infarction, and acute mn)ocartbal infarcito. uere 6 4 100 oer"I for wujeit%agled 140 wean ill 4 1010 f#w type A iubtectt. 4 2 100 fr nontIpe A or ty-pe ft %Uh)jrctti (RtiCnMan ei l 1 97441 the predicted 12)ecar occurvrnct ratv- lor the wumer of our mtud). 21 1010 at 11- U )eau%. I ' It00 at "1-44 yearm and 10 4 101) at 41-49 sean. teem %ef3 cortipaui to the data fro'm the u'ther -Alute when %.ortected it) the tame timne %pan%The apparent frequenc) of :ufrcnth. detectat'k (HI) in the tut'tect' of the NCllS etamination weit%t(.or'do aOd (iarm 1961) uould. in fact. indicate uowne'hat higher ratet of ,wurtvnc in the %ubjecta of that trie% ompaired to the o1ther %tudhei Sidant diffctvn4ct in approach, hotwe~cr. must not he oterho-ed Though according it) the cmntra uted the men oft the mihnne te %cew do not teem to he more % ulncrable to, ..oronar) heart dijeate than male%of ther United Statct populatxmni. the) neecrthelet appear to he at leatt m~ wwtepteble as other populatiobn Vp, Since these mn helong to a phs wialkt tomiethat telet Wtpptioin and mutt remnaen rcammuNl. health) to .continue in the tubmnn terice. it is apparent that to fulfill the health potential of this grop ~.omplce% . there it xwicerahk rown for improtement in hahut%. enwourriental comrponentt. and! ther factors that contnhute to health Fix"i the etadence presented in Table 4 that indicate' that the total amoiunt of cigarette tntokang among men of the highest ager groupa eem%to hue decreatung omewbat comrpared to the )oungpctrimen. it is possible to derive %one encouragemaent fini the fact that there am) he changet in living tyles that will lead erventuall) ito, a lo-Acrng of CHD risk Irosement in this and other modifiable farom% at youniger sot couldl etentuall lead to a helter progntsrt for the cardsosasc~ular health of thi%popullation. W* mv wok!d to aumi~ 'enfwe Tmmwi l~rdi mu to Ow mdiano wi pulxwqWa On. dw3 Tlw at a"s , a Pl 10VNavel Makeal ftaWaft WellDtapoW('1mm g~ Wout 1101MM~ I L Of4M wft"v mw~ P",.r-0 06. p of*" Wie, mm,s otnd 4mos 1978 ~Ie tap~iaa s'IWmom'a. L w) hi I 1a8"j. aOW E 14,1*1 I"7 Fmem de nsqiac aovaecodwor ches 1.011,m -smnow tViirwo 111' Ret Su' SNWp S201-&215 -Flasmm %rua4t%htorhamqwee h*nmtkVpqwes. ts ptychohkitpies. tignikaave por le petamimtic des mahde' deps1ieutvn 01 "W10111 ,sm I" Imublif maiuwu. wall iwet dw 1.017 umsnawunmn t ph cutaat em pis ipaa cfit ont eajits q chit b ~t des hon. Wm AV conme Le wost adt~it tatal te tuv dame In If ie do Pin . ILAAMoitmll li. In Cittiit. kSpoid% irht. et bs timeffifief "m lie haimi 440clie rmpiaminkt d neqi, cadrwafcuhin &i cc gmpmigwoi u s. simu-minieum w i b ia piu phsexpaoe a u,,*m cardwmaocubtirw qm drtrwsu Awmmm. aim%aom oburti qm It 0* MMe deb4.La fm wn.sioaetu t4mir l. s s afiile &mq ft ats a 1 me.d fileUs erditsoubmqwm afflabm ONto Q84p~n a n Pt Oficm 4 Opp- d S214 TAPPAN. WVONlEY. JACEY. AND HEYDIE3 dare, cm It naqase caidaoaamu ei Is cnsimi~mmmIs deiFalool oudua Cde. des c&srretawua uymwaoaults ONt w bowse Ces ladoalt. avftla chiiieterlemae. lW% Coftltet. Cl kePSo% felatd. doa%eal tCU, -onaadee COWin det fa-CetUSS 11110fial)les Chtae nm prouver us rqmp.2 btar de n~qaw cuaotasculium perummal mabztaut '.b,lrokmu ..miMMUIta. dt I AkOal REFEREN(IS Slag. It J Hi Tkluama.. ami S Ide&.a VV% %Icua~b etlitt%tal ak-tshol tie the bean Afl3 N V Acad !k1141W-2"9 &VIA. K R L K It Ver). and K t Sdmaefer 1973 (arftktqeog~u*% Ivcl%duig; a %wwu patmil Aym~ Spk-aeFarti Med 49 I.14td1 Brtoid. ft J . ft H Roteeman., R I Scholts. and M Inedrm 1976 hlufttnaie piv~wtawo of coauarl beani liseasw - the wee (kJaswaae Group %limb tnwv to r."&..p of the i-rommog. .aILd (ajmruamss i to- 11 andge.. It 4 . I H Kraal..I I I Hnam, and M 9 Clumwellr9W~a I wti of tcco,amn~e tin 4beewb.,S Sad ShKOW autabobtal Of n4lVW"Ph~w~Maa Ieukoc)iea Infect iNMNg 14 III- 121 Bndoe,. Rt 3. J H K,,imi. U J t Ifama. and M 8 Owsincellw 197 I-ftit ti clpntir mooke Co00"isms I'm min m cheuatai of hum"a p -Answ bwmka WLSWadasx~ Inlet Imuman If, (C0611e6I. J . MW S Mikihell 1%9 Selm" rv aclorsa coios,#i haas Aidh Vatirm Health 19 Fbonet H C . WW W King. vil Igh hq . l.ab. 15, :10 t Hanmaftafs 4mb 1 lot ow data (lseaa Ruwbr CO. (letehad Fiahel. 8 . md H A Sbabrick 19 Tobaecco maiibe toutwl. loss of huam levowlac I'vctiom amid tlund call wetatwsba ieace 166 1414 - t429 rineimma. M 1969 Potballeesis of comanr mome disease MC~icau Hill. SN Friedmim. M a. ft H Rotinaw 1919 Amwocwkm f slaqpi ate he awpanis w wth Mood and ,Caribovaacubw Andse.. JAMA 169 1206'- 12% Inemi. M .m &W t H Rotcama 1974 Type A bhaaa* sad )outr been Kno. N V Frckb her. V F . ik . ai C lancamari 19'1 PiwmVeae of atbeftaaakrowe hstas -- 4pmAtwlst Ice mbs m ,- 'Icua Aeuap NW 64 U.2- %" Glims. D C 19" Sifwtwba.-vor pali. Ond coma disease Am0SCI Wt I"- IV~ (joethi. T . iad C U(lGent 190 (7oomery bean dm4 asta&*&h asthe Usod States 1%0- 132 I'SP1NS Pahal No 1000 tevet 11. No 10 1. S (krwweneet Pntng (Mvt. Washmpom. D C Ceudam. T . aid W 8 Kmwul 1971 The Frimmamm anud% an epiideuuakapl utvei*ptwol of cardWVt.,Aah 4111ave SeCtlvin 26-.'? I, S GiWrVMaee Pfnj (ce. Wabran. D C Comwa. Rt N . ) Demaki. S H tahimook. M S Stem. and J f. To%*. Jr 1975 Clwwal s~s and assuial lho of alcaobc her disae nm N4V Acad So M'23-, HAlpena. N . W C RamcweleW. ald J I Vetle 1971 Fltawmasi of the minviwanate lopwtt flak fuicime a conpanu ti th Owacnnwmau firacirwr andj waimnnm Whlihboid approaches I Orom Dih .14 12-It" Hoffima.W S 11064aae enno ilNed tei Vmai eia u'ae~ b~ lebm. C D, 5 1 Zyamd. mail f H ftoaeu 1197 RAth of myoucarial mmilartioe smaidilk-41d Wm *fth Mammlest cor"Oe.i beat dimeet Clrruhao 41 U42 -47 Kaimeal. W 8 97T4The role df hpmd. wwd take pmwew m the de'vkapen I o crmry bowt dAmme G htal C-Aido 4 I21Z37 Kasmel. W 3 . W P Cml. P N McNimarm. P A McKee. aid U Psd1@ 191 Robe of'Wod Knowel. W 3 . sod 1 t R Dwtve 192. Cometreamss to ceaw nmb Iamplcafta fix pebi bmma OweFmum wudy. Nowsad Low 1.7 07 -00 Kawek W. a. M. HJrumd. "nd w P Comm. 1W7 Robe of I - i awv hbun - I : the ?r.Umm Ssuf Am 1. Car". NO29-34. LAmy. ft 1. and N.FW Pif" ~9DEm. lil p'Ap -aid ammowbi Fra 89-9). m ft. S. nfondk aiid M 2 Sb . W Un an-m i haf and dem. . . L@ aid lPeI. Omop AIWN. tAce Md. 9d. 232: 6346 C'ARDk)VASCUI-AR RISK FACTORS Meyver - I Neahh Moorc. F lHRAl Rega. T S215 973 Obett Pmlln 625 -"4 UPR S Gjodban OWd Mi- ShfA. Uds Modur Nutnteom a andf Diae Lesand Febur. FPudadephm F 197) Seum choleaserl levh to adultz a Uted States. 1960- 1I62 DHEW PubN No 742113 L, S Goieramest Pnuoaag (Xfc. Washampos. MC J . P 0 FtaneucH A Oldwunel.andD8 Haider 1975 Heartcel rspnest aedhal. Am. N Y Acad Scs 2 24- Rowuama. R H . I Brand. D Jeakm%. Mi Fnedmna. R Strumb. owl hi. Wi.,. 1971. CoronwV beal &%-877a the Wti~ws wilhboracive goup ad Final k&--up eapwpm of Pi Vests JAMA 23 Sauw. R N . witt. J H Baker 1972. The kouilaaaa bealth study I Deacnptao NairSubhied Rua~h Reporn So 7'% Sacqecor.G W .and * GCi(ochnin 1967 Stsraal mevtid 61h ad 3m Stw Vmv PWWm, Anna. PP Slosik. H W , A Damon. R A M6iFartan. smd I Roberts 1971 Skadold. hidfr pith. butcomal Aamete, and ekc led anhri'pwtrw m~ mscta a"%h m Unsed State% IVA- 1962 DIFW PWN No i HRA 1 '4 1331 U S C(veusest PnaUrn Ee.Wnason D C Sanaf I D. F 1) Bureta. 1. 9 Phet. F 9 Stuart. I H KaJdleb.UB Vam Ywrloo. ad A LA Ranns 974 ('adtanwko leveh m Amencan Wood downv )AMA L19 1187- 11" Talbot. 1) 1974 Pntmarn akvbLw bean sMea.w Am N V Acad SLi. t, 27-242 tavvwr. % A I974 Mhkwogajbnal bekat%d) a asaluphaw medical wrvillaae pnoum for V S Na~o)wuaenne ad di'ag pet~Awonre Na%SubMedRmclab Reporn No 331 rappes. D) V . Mi I lftxe. t Hey4e1. awl C A Harvey 1979 Sionedcal mad hemstoW p"Ies at a diouaaand uhmansn LUn"calomed Res SubtSwppl S39,. SIW Tappan D) V. Mi J Jacev. F Hcden, ad W A Tammy~ 1971 fhowtedkai pnolifrs cl athmrwn a kwmaaa beak). sad% NaSubiedftcbltAb Report No' 0t Truett. J I Cog nitid. andf W A Kassel 1967 A amilaranaft maxi)'a' ONthe fnk of teniarv beart dowam m rurbam J (box M .0 %1-Iiq24 Wesbera&. 8 8 1971 Subatene ca effecbwess dune$gg aubmanne ofuan %au,) daysa ore duaion Na~IMdsh .Report No f WrVM. H F . sd I H Wimog, 1974 f suamaon of relauve body (at and la hodv aweg a a Ummed Stale Manse Cawp' opuatom AerWna Med 44 .101 - -M Mst