Andrew Grandinetti

Frequency of bowel movements and the future risk of Parkinson’s disease

Background: Constipation is frequent in PD, although its onset in relation to clinical PD has not been well described. Demonstration that constipation can precede clinical PD could provide important clues to understanding disease progression and etiology. The purpose of this report is to examine the association between the frequency of bowel movements and the future risk of PD. Methods: Information on the frequency of bowel movements was collected from 1971 to 1974 in 6790 men aged 51 to 75 years without PD in the Honolulu Heart Program. Follow-up for incident PD occurred over a 24-year period. Results: Ninety-six men developed PD an average of 12 years into follow-up. Age-adjusted incidence declined consistently from 18.9/10,000 person-years in men with <1 bowel movement/day to 3.8/10,000 person-years in those with >2/day (p = 0.005). After adjustment for age, pack-years of cigarette smoking, coffee consumption, laxative use, jogging, and the intake of fruits, vegetables, and grains, men with <1 bowel movement/day had a 2.7-fold excess risk of PD versus men with 1/day (95% CI: 1.3, 5.5; p = 0.007). The risk of PD in men with <1 bowel movement/day increased to a 4.1-fold excess when compared with men with 2/day (95% CI: 1.7, 9.6; p = 0.001) and to a 4.5-fold excess versus men with >2/day (95% CI: 1.2, 16.9; p = 0.025). Conclusions: Findings indicate that infrequent bowel movements are associated with an elevated risk of future PD. Further study is needed to determine whether constipation is part of early PD processes or is a marker of susceptibility or environmental factors that may cause PD.

Cigarette smoking and protection from Parkinson's disease False association or etiologic clue?

Article abstract—We reviewed 46 published reports associating cigarette smoking and Parkinsons disease. Although the majority indicated an approximate halving of smoking frequency in persons with Parkinsons disease, many observers have suggested that the effect could be a spurious result. That the association may be real is suggested by at least six observations: (1) the consistency of findings between independent studies of different design, conducted by different investigators, in different nations, over 35 years; (2) the associations predominance and strength in prospective studies; (3) the apparent detection of a dose-response relation; (4) the inability to explain the association by confounding variables; (5) the flaws in certain arguments against the associations validity; and (6) the identification of a similar association, of similar magnitude, between smoking and reduced occurrence of Alzheimers disease. A protective association of cigarette smoking for Parkinsons disease may constitute an important etiologic clue.

Epidemiologic observations on Parkinson's disease Incidence and mortality in a prospective study of middle-aged men

We determined age-specific and age-adjusted incidence rates and mortality rates of idiopathic Parkinsons disease (PD) in a cohort of men followed for 29 years. Since enrollment in 1965, the Honolulu Heart Study has followed 8,006 American men of Japanese or Okinawan ancestry. Rescreening of the entire cohort, completed in 1994, included attempts to detect all prevalent and incident cases of PD, parkinsonism, and related conditions. PD incidence rates and age-incidence patterns were similar to rates previously published for Caucasian men in Europe and the United States, and were higher than incidence rates published for Asian men living in Asian nations. Prevalence patterns appeared to correspond more closely to patterns observed in developed nations than in Asian nations. PD was associated with markedly increased mortality that appeared to result from effects of both absolute age and disease duration. There was no firm evidence for differences in birth cohort risks of PD. These data may have implications for maturational and environmental theories of PD etiology. NEUROLOGY 1996;46: 1044-1050.

Dietary Fiber, Magnesium, and Glycemic Load Alter Risk of Type 2 Diabetes in a Multiethnic Cohort in Hawaii

The influence of dietary fiber, magnesium (Mg), and glycemic load (GL) on diabetes was examined in the Hawaii component of the Multiethnic Cohort. The 75,512 Caucasian, Japanese American, and Native Hawaiian participants aged 45-75 y at baseline completed a FFQ. After 14 y of follow-up, 8587 incident diabetes cases were identified through self-reports and health plans. We applied Cox regression stratified for age at cohort entry and adjusted for ethnicity, BMI, physical activity, education, and total energy with further stratifications by sex and ethnicity. When comparing extreme quintiles, total fiber intake was associated with reduced diabetes risk among all men [hazard ratio (HR): 0.75; 95% CI: 0.67, 0.84; P-trend < 0.001) and women (HR: 0.95; 95% CI: 0.85, 1.06; P-trend = 0.05). High intake of grain fiber reduced diabetes risk significantly by 10% in men and women. High vegetable fiber intake lowered risk by 22% in all men but not women. Mg intake reduced risk (HR = 0.77 and 0.84 for men and women, respectively) and, due to its strong correlation with fiber (r = 0.83; P < 0.001), may explain the protective effect of fiber. The top GL quintile was associated with a significantly elevated diabetes incidence in Caucasian men and in all women except Japanese Americans. Overall, several associations were more pronounced in Caucasians than in the other groups. These findings suggest that protection against diabetes can be achieved through food choices after taking into account body weight, but, due to differences in commonly consumed foods, risk estimates may differ by ethnic group.

The Influence of Obesity on Chronic Venous Disease

The authors investigate the impact of overweight in patients with chronic venous disease and determine if the eventual effect can be explained by increased venous reflux alone. Patients with chronic venous disease who underwent duplex-ultrasound scanning at the Vascular Center, Straub Clinic and Hospital during 1999 were classified according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and body mass index (kg/M2) was calculated. Reflux duration was measured in seconds and peak reverse flow velocity in cm/second. Multisegment reflux score (total score) was calculated for both reflux duration and peak reverse flow velocity. The reflux pattern and body mass index were correlated to the clinical presentation. Four hundred and one lower extremities (204 right, 197 left) in 272 patients (173 female) with a mean age of 60 years (range 14-90) were investigated. The mean body mass index was 28.9 (±7.76). One hundred sixty-seven patients (61%) were overweight (body mass index 25 kg/M2 or more). There was a significant association between body mass index and the clinical severity (p < 0.001). This association persisted after adjustments for total peak reverse flow velocity and total reflux score were made (p <0.001). Overweight patients were more likely to have skin changes and ulceration (p < 0.001) than patients with a body mass index less than 25 kg/m2, despite similar values for total reflux time (p = 0.92) and total peak reverse flow velocity (p = 0.98). There was an ethnic difference, with Pacific Islanders being significantly heavier and younger compared to patients of white, Asian and Filipino ancestries. The variations in the frequency of skin changes were consistent with ethnic differences in body mass index. The correlation of body mass index with clinical severity independent of reflux measurements indicates that the effect of overweight may involve a mechanism separate from local effects on venous flow. Overweight appears to be a separate risk factor for increased severity of skin changes in patients with chronic venous disease.

Dietary Patterns and Risk for Diabetes: The Multiethnic Cohort

OBJECTIVE The high diabetes incidence among Japanese Americans and Native Hawaiians cannot be explained by BMI. Therefore, we examined the influence of three dietary patterns of “fat and meat,” “vegetables,” and “fruit and milk” on diabetes risk in the Hawaii component of the Multiethnic Cohort with 29,759 Caucasians, 35,244 Japanese Americans, and 10,509 Native Hawaiians. RESEARCH DESIGN AND METHODS Subjects aged 45–75 years completed a baseline food frequency questionnaire. After 14 years of follow-up, 8,587 subjects with incident diabetes were identified through self-reports or health plan linkages. Risk was assessed using Cox regression stratified by age and adjusted for ethnicity, BMI, physical activity, education, total energy, smoking, alcohol intake, marital status, and hypertension. RESULTS Fat and meat was significantly associated with diabetes risk in men (hazard ratio 1.40 [95% CI 1.23–1.60], Ptrend < 0.0001) and women (1.22 [1.06–1.40], Ptrend = 0.004) when extreme quintiles were compared. Except in Hawaiian women, the magnitude of the risk was similar across ethnic groups although not always significant. After stratification by BMI, fat and meat remained a predictor of disease primarily among overweight men and among overweight Japanese women. Vegetables lowered diabetes risk in men (0.86 [0.77–0.95], Ptrend = 0.004) but not in women, whereas fruit and milk seemed to be more beneficial in women (0.85 [0.76–0.96], Ptrend = 0.005) than in men (0.92 [0.83–1.02], Ptrend = 0.04). CONCLUSIONS Foods high in meat and fat appear to confer a higher diabetes risk in all ethnic groups, whereas the effects of other dietary patterns vary by sex and ethnicity.

Prevalence of Glucose Intolerance Among Native Hawaiians in Two Rural Communities

OBJECTIVE To estimate prevalence of type 2 diabetes and impaired glucose tolerance (IGT) among a population of native Hawaiians in two rural communities. RESEARCH DESIGN AND METHODS Prevalence of glucose intolerance was assessed in two rural communities by history (confirmed by record review) or with a 75-g oral glucose tolerance test according to World Health Organization criteria. Anthropometric and demographic data were also obtained. A short survey was used to estimate the prevalence of known diabetes among nonparticipants. Prevalence rates were adjusted using the standard world population of Segi. RESULTS A total of 574 native Hawaiians age ≥30 years participated. The crude prevalence of IGT and type 2 diabetes were 15.5 and 20.4%, respectively. Only IGT prevalence was significantly higher (P = 0.03) among women (18.7%) than among men (10.9%). Prevalence of glucose intolerance was significantly associated with BM1, waist circumference, and waistto-hip ratio (WHR). After adjusting for age and BMI, waist circumference and WHR were significantly and independently associated with type 2 diabetes prevalence only among women. Prevalence of type 2 diabetes was not significantly associated with the percentage of Hawaiian ancestry after adjusting for age. CONCLUSIONS This study observed a high prevalence of glucose intolerance associated with being overweight among native Hawaiians. Age-adjusted type 2 diabetes prevalence was four times higher than among the U.S. National Health and Nutrition Examination Survey (NHANES) II population. Prevalence was high despite high rates of admixture with other ethnic groups of Hawaii, suggesting that these other Asian and Pacific Island populations share similar susceptibility to type 2 diabetes risk.

Diabetes Incidence Based on Linkages with Health Plans: The Multiethnic Cohort

OBJECTIVE Using the Hawaii component of the Multiethnic Cohort (MEC), we estimated diabetes incidence among Caucasians, Japanese Americans, and Native Hawaiians. RESEARCH DESIGN AND METHODS After excluding subjects who reported diabetes at baseline or had missing values, 93,860 cohort members were part of this analysis. New case subjects were identified through a follow-up questionnaire (1999–2000), a medication questionnaire (2003–2006), and linkage with two major health plans (2007). We computed age-standardized incidence rates and estimated hazard ratios (HRs) for ethnicity, BMI, education, and combined effects of these variables using Cox regression analysis. RESULTS After a total follow-up time of 1,119,224 person-years, 11,838 incident diabetic case subjects were identified with an annual incidence rate of 10.4 per 1,000 person-years. Native Hawaiians had the highest rate with 15.5, followed by Japanese Americans with 12.5, and Caucasians with 5.8 per 1,000 person-years; the adjusted HRs were 2.65 for Japanese Americans and 1.93 for Native Hawaiians. BMI was positively related to incidence in all ethnic groups. Compared with the lowest category, the respective HRs for BMIs of 22.0–24.9, 25.0–29.9, and ≥30.0 kg/m2 were 2.10, 4.12, and 9.48. However, the risk was highest for Japanese Americans and intermediate for Native Hawaiians in each BMI category. Educational achievement showed an inverse association with diabetes risk, but the protective effect was limited to Caucasians. CONCLUSIONS Within this multiethnic population, diabetes incidence was twofold higher in Japanese Americans and Native Hawaiians than in Caucasians. The significant interaction of ethnicity with BMI and education suggests ethnic differences in diabetes etiology.

Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease ☆

OBJECTIVE We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease. PATIENTS AND METHODS Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6). RESULTS The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone (P =.025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity (P =.006), but the difference for total reflux time did not reach significance (P =.084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P =.25). CONCLUSION Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.

Major dietary patterns, ethnicity, and prevalence of type 2 diabetes in rural Hawaii

OBJECTIVE The association of type 2 diabetes (T2DM) with the overall dietary pattern and its relation with ethnicity was examined. METHODS A cross-sectional study with 1257 participants with four ethnicities (Caucasian, Filipino, Native Hawaiian, and Japanese) in the North Kohala region of Hawaii was conducted. Participants 18-95 y of age were surveyed for their ethnic and demographic backgrounds, dietary intakes, and biochemical indexes of glucose intolerance between 1997 and 2000. RESULTS Three dietary patterns from the food-frequency questionnaire were identified by factor analysis. Factor 1 was characterized by a healthy diet with a frequent intake of vegetables and fruits, and factor 2 was dominated by animal foods and local ethnic dishes. Factor 3 was characterized by a Western diet, which was dominated by French fries, fast-food hamburgers, pizza, and chips. Multivariate logistic regression model for T2DM prevalence included ethnicity and three dietary factors after adjustment for age, sex, income, physical activity, smoking status, and energy intake. Ethnicity was significantly associated with T2DM, with an odds ratio of 1.83 (95% confidence interval [CI] 1.12-3.00) for Native Hawaiians and 1.92 (95% CI 1.12-3.29) for Filipinos compared with Caucasians 1.92 (95% CI 1.12-3.29). Among the three dietary factors, factor 2 was positively associated with T2DM (odds ratio 1.30, 95% CI 1.03-1.68), but the significance disappeared after adjustment for energy intake. CONCLUSION The findings show that ethnicity is a stronger risk factor for T2DM than dietary patterns when energy intake is adjusted for. Reducing energy intake to prevent T2DM deserves more attention during health promotion for the multiethnic population of Hawaii.