Henry A. Feldman

Impotence and Its Medical and Psychosocial Correlates: Results of the Massachusetts Male Aging Study

We provide current, normative data on the prevalence of impotence, and its physiological and psychosocial correlates in a general population using results from the Massachusetts Male Aging Study. The Massachusetts Male Aging Study was a community based, random sample observational survey of noninstitutionalized men 40 to 70 years old conducted from 1987 to 1989 in cities and towns near Boston, Massachusetts. Blood samples, physiological measures, socio-demographic variables, psychological indexes, and information on health status, medications, smoking and lifestyle were collected by trained interviewers in the subjects home. A self-administered sexual activity questionnaire was used to characterize erectile potency. The combined prevalence of minimal, moderate and complete impotence was 52%. The prevalence of complete impotence tripled from 5 to 15% between subject ages 40 and 70 years. Subject age was the variable most strongly associated with impotence. After adjustment for age, a higher probability of impotence was directly correlated with heart disease, hypertension, diabetes, associated medications, and indexes of anger and depression, and inversely correlated with serum dehydroepiandrosterone, high density lipoprotein cholesterol and an index of dominant personality. Cigarette smoking was associated with a greater probability of complete impotence in men with heart disease and hypertension. We conclude that impotence is a major health concern in light of the high prevalence, is strongly associated with age, has multiple determinants, including some risk factors for vascular disease, and may be due partly to modifiable para-aging phenomena.

Incidence of erectile dysfunction in men 40 to 69 years old : Longitudinal results from the Massachusetts male aging study

PURPOSE We estimated the incidence of erectile dysfunction in men 40 to 69 years old at study entry during an average 8.8-year followup, and determined how risk varied with age, socioeconomic status and medical conditions. MATERIALS AND METHODS Data from a randomly sampled population based longitudinal study of Massachusetts men were analyzed. A total of 1,709 men completed the baseline interview during 1987 to 1989 and 1,156 survivors completed followup from 1995 to 1997. The analysis sample consisted of 847 men without erectile dysfunction at baseline and with complete followup information. Erectile dysfunction was assessed by discriminant analysis of 13 questions from a self-administered sexual function questionnaire and a single global self-rating question. RESULTS The crude incidence rate for erectile dysfunction was 25.9 cases per 1,000 man-years (95% confidence interval [CI] 22.5 to 29.9). The annual incidence rate increased with each decade of age and was 12.4 cases per 1,000 man-years (95% CI 9.0 to 16.9), 29.8 (24.0 to 37.0) and 46.4 (36.9 to 58.4) for men 40 to 49, 50 to 59 and 60 to 69 years old, respectively. The age adjusted risk of erectile dysfunction was higher for men with lower education, diabetes, heart disease and hypertension. Population projections for men 40 to 69 years old suggest that 17,781 new cases of erectile dysfunction in Massachusetts and 617,715 in the United States (white males only) are expected annually. CONCLUSIONS Although prevalence estimates and cross-sectional correlates of erectile dysfunction have recently been established, incidence estimates were lacking. Incidence is necessary to assess risk, and plan treatment and prevention strategies. The risk of erectile dysfunction was about 26 cases per 1,000 men annually, and increased with age, lower education, diabetes, heart disease and hypertension.

THE RELATIONSHIP BETWEEN DEPRESSIVE SYMPTOMS AND MALE ERECTILE DYSFUNCTION: CROSS-SECTIONAL RESULTS FROM THE MASSACHUSETTS MALE AGING STUDY

Objective Studies have shown that there is an association between depression and male erectile dysfunction (MED). However, these earlier studies suffer considerable methodological flaws including: a) lack of a multidisciplinary approach; b) poor sampling techniques; and finally, c) poor and variable measures of MED and depression. Our objectives are: a) to determine whether MED is associated with depressive symptoms and b) to determine whether this association is independent of aging and para-aging factors. Method Data were obtained from the Massachusetts Male Aging Study (MMAS). The MMAS was a cross-sectional, population-based multidisciplinary survey of health in normally aging men (aged 40-70 years) conducted from 1986 to 1989. In the analytic model, depressive symptoms, as measured by a score of 16 or greater on the Center for Epidemiological Studies-Depression (CES-D) scale, was used as a predictor of MED, which was assessed with a self-administered questionnaire. Results MED was associated with depressive symptoms after controlling for potential confounders (odds ratio (OR) 1.82, 95% confidence interval (CI) 1.21-2.73). Conclusions We conclude that the relationship between depressive symptoms and MED in middle-aged men is robust and independent of important aging and para-aging confounders, such as demographic, anthropometric and lifestyle factors, health status, medication use, and hormones.

Effects of Decreasing Sugar-Sweetened Beverage Consumption on Body Weight in Adolescents: A Randomized, Controlled Pilot Study

OBJECTIVE. The role of sugar-sweetened beverages (SSBs) in promoting obesity is controversial. Observational data link SSB consumption with excessive weight gain; however, randomized, controlled trials are lacking and necessary to resolve the debate. We conducted a pilot study to examine the effect of decreasing SSB consumption on body weight. METHODS. We randomly assigned 103 adolescents aged 13 to 18 years who regularly consumed SSBs to intervention and control groups. The intervention, 25 weeks in duration, relied largely on home deliveries of noncaloric beverages to displace SSBs and thereby decrease consumption. Change in SSB consumption was the main process measure, and change in body mass index (BMI) was the primary end point. RESULTS. All of the randomly assigned subjects completed the study. Consumption of SSBs decreased by 82% in the intervention group and did not change in the control group. Change in BMI, adjusted for gender and age, was 0.07 ± 0.14 kg/m2 (mean ± SE) for the intervention group and 0.21 ± 0.15 kg/m2 for the control group. The net difference, −0.14 ± 0.21 kg/m2, was not significant overall. However, baseline BMI was a significant effect modifier. Among the subjects in the upper baseline-BMI tertile, BMI change differed significantly between the intervention (−0.63 ± 0.23 kg/m2) and control (+0.12 ± 0.26 kg/m2) groups, a net effect of −0.75 ± 0.34 kg/m2. The interaction between weight change and baseline BMI was not attributable to baseline consumption of SSBs. CONCLUSIONS. A simple environmental intervention almost completely eliminated SSB consumption in a diverse group of adolescents. The beneficial effect on body weight of reducing SSB consumption increased with increasing baseline body weight, offering additional support for American Academy of Pediatrics guidelines to limit SSB consumption.

Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group.

OBJECTIVE To assess the outcomes of health behavior interventions, focusing on the elementary school environment, classroom curricula, and home programs, for the primary prevention of cardiovascular disease. DESIGN A randomized, controlled field trial at four sites with 56 intervention and 40 control elementary schools. Outcomes were assessed using prerandomization measures (fall 1991) and follow-up measures (spring 1994). PARTICIPANTS A total of 5106 initially third-grade students from ethnically diverse backgrounds in public schools located in California, Louisiana, Minnesota, and Texas. INTERVENTION Twenty-eight schools participated in a third-grade through fifth-grade intervention including school food service modifications, enhanced physical education (PE), and classroom health curricula. Twenty-eight additional schools received these components plus family education. MAIN OUTCOME MEASURES At the school level, two primary end points were changes in the fat content of food service lunch offerings and the amount of moderate-to-vigorous physical activity in the PE programs. At the level of the individual student, serum cholesterol change was the primary end point and was used for power calculations for the study. Individual level secondary end points included psychological factors, recall measures of eating and physical activity patterns, and other physiologic measures. RESULTS In intervention school lunches, the percentage of energy intake from fat fell significantly more (from 38.7% to 31.9%) than in control lunches (from 38.9% to 36.2%)(P<.001). The intensity of physical activity in PE classes during the Child and Adolescent Trial for Cardiovascular Health (CATCH) intervention increased significantly in the intervention schools compared with the control schools (P<.02). Self-reported daily energy intake from fat among students in the intervention schools was significantly reduced (from 32.7% to 30.3%) compared with that among students in the control schools (from 32.6% to 32.2%)(P<.001). Intervention students reported significantly more daily vigorous activity than controls (58.6 minutes vs 46.5 minutes; P<.003). Blood pressure, body size, and cholesterol measures did not differ significantly between treatment groups. No evidence of deleterious effects of this intervention on growth or development was observed. CONCLUSION The CATCH intervention was able to modify the fat content of school lunches, increase moderate-to-vigorous physical activity in PE, and improve eating and physical activity behaviors in children during 3 school years.

Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? ☆

OBJECTIVES To prospectively examine whether changes in smoking, heavy alcohol consumption, sedentary lifestyle, and obesity are associated with the risk of erectile dysfunction. METHODS Data were collected as part of a cohort study of a random sample of men 40 to 70 years old, selected from street listings in the Boston Metropolitan Area, Massachusetts. In-home interviews were completed by 1709 men at baseline in 1987 to 1989 and 1156 men at follow-up in 1995 to 1997 (average follow-up 8.8 years). Analyses included 593 men without erectile dysfunction at baseline, who were free of prostate cancer, and had not been treated for heart disease or diabetes. The incidence of moderate to complete erectile dysfunction was determined by discriminant analysis of responses to a self-administered sexual function questionnaire. RESULTS Obesity status was associated with erectile dysfunction (P = 0.006), with baseline obesity predicting a higher risk regardless of follow-up weight loss. Physical activity status was associated with erectile dysfunction (P = 0.01), with the highest risk among men who remained sedentary and the lowest among those who remained active or initiated physical activity. Changes in smoking and alcohol consumption were not associated with the incidence of erectile dysfunction (P >0.3). CONCLUSIONS Midlife changes may be too late to reverse the effects of smoking, obesity, and alcohol consumption on erectile dysfunction. In contrast, physical activity may reduce the risk of erectile dysfunction even if initiated in midlife. Early adoption of healthy lifestyles may be the best approach to reducing the burden of erectile dysfunction on the health and well-being of older men.

A Randomized Trial of Sugar-Sweetened Beverages and Adolescent Body Weight

BACKGROUND Consumption of sugar-sweetened beverages may cause excessive weight gain. We aimed to assess the effect on weight gain of an intervention that included the provision of noncaloric beverages at home for overweight and obese adolescents. METHODS We randomly assigned 224 overweight and obese adolescents who regularly consumed sugar-sweetened beverages to experimental and control groups. The experimental group received a 1-year intervention designed to decrease consumption of sugar-sweetened beverages, with follow-up for an additional year without intervention. We hypothesized that the experimental group would gain weight at a slower rate than the control group. RESULTS Retention rates were 97% at 1 year and 93% at 2 years. Reported consumption of sugar-sweetened beverages was similar at baseline in the experimental and control groups (1.7 servings per day), declined to nearly 0 in the experimental group at 1 year, and remained lower in the experimental group than in the control group at 2 years. The primary outcome, the change in mean body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) at 2 years, did not differ significantly between the two groups (change in experimental group minus change in control group, -0.3; P=0.46). At 1 year, however, there were significant between-group differences for changes in BMI (-0.57, P=0.045) and weight (-1.9 kg, P=0.04). We found evidence of effect modification according to ethnic group at 1 year (P=0.04) and 2 years (P=0.01). In a prespecified analysis according to ethnic group, among Hispanic participants (27 in the experimental group and 19 in the control group), there was a significant between-group difference in the change in BMI at 1 year (-1.79, P=0.007) and 2 years (-2.35, P=0.01), but not among non-Hispanic participants (P>0.35 at years 1 and 2). The change in body fat as a percentage of total weight did not differ significantly between groups at 2 years (-0.5%, P=0.40). There were no adverse events related to study participation. CONCLUSIONS Among overweight and obese adolescents, the increase in BMI was smaller in the experimental group than in the control group after a 1-year intervention designed to reduce consumption of sugar-sweetened beverages, but not at the 2-year follow-up (the prespecified primary outcome). (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; ClinicalTrials.gov number, NCT00381160.).

Validation of interviewer- and self-administered physical activity checklists for fifth grade students.

The purpose of the study was to evaluate two physical activity recall instruments appropriate for use in epidemiologic studies of fifth grade children. The instruments were similar, except one (PACI) was administered in a personal interview, and the other (SAPAC) was self-completed in a group setting. Both forms required children to report the minutes during the previous day they spent in 21 common physical activities that represented a range of intensities, plus sedentary pursuits. To validate the recalls, children simultaneously wore an accelerometer (motion sensor) and a heart rate monitor for at least 8 h the day before the interview. Subjects were 55 boys and 70 girls from four regions of the United States. The Pearson correlation between the self- and interviewer-administered forms was 0.76 (P < 0.001). The interviewer-administered form correlated 0.51 (P < 0.001) with the heart rate index and 0.33 (P < 0.001) with the accelerometer score. The self-administered form correlated 0.57 (P < 0.001) with the heart rate index and 0.30 (P < 0.001) with the accelerometer score. It is concluded that both self-report forms received moderate support for their validity in all gender and ethnic subgroups. The self-administered format is more cost-effective.

The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk.

OBJECTIVES Whether community-wide education changed cardiovascular risk factors and disease risk in Pawtucket, RI, relative to a comparison community was assessed. METHODS Random-sample, cross-sectional surveys were done of people aged 18 through 64 years at baseline, during, and after education. Baseline cohorts were reexamined. Pawtucket citizens of all ages participated in multilevel education, screening, and counseling programs. RESULTS The downward trend in smoking was slightly greater in the comparison city. Small, insignificant differences favored Pawtucket in blood cholesterol and blood pressure. In the cross-sectional surveys, body mass index increased significantly in the comparison community; a similar change was not seen in cohort surveys. Projected cardiovascular disease rates were significantly (16%) less in Pawtucket during the education program. This difference lessened to 8% posteducation. CONCLUSIONS The hypothesis that projected cardiovascular disease risk can be altered by community-based education gains limited support from these data. Achieving cardiovascular risk reduction at the community level was feasible, but maintaining statistically significant differences between cities was not. Accelerating risk factor changes will likely require a sustained community effort with reinforcement from state, regional, and national policies and programs.

Prevalence of Vitamin D Deficiency Among Healthy Infants and Toddlers

OBJECTIVES To determine the prevalence of vitamin D deficiency and to examine whether 25-hydroxyvitamin D (25OHD) concentration varies as a function of skin pigmentation, season, sun exposure, breastfeeding, and vitamin D supplementation. DESIGN Cross-sectional sample. SETTING Urban primary care clinic. PARTICIPANTS Healthy infants and toddlers (N = 380) who were seen for a routine health visit. OUTCOME MEASURES Primary outcomes were serum 25OHD and parathyroid hormone levels; secondary measures included data on sun exposure, nutrition, skin pigmentation, and parental health habits. Wrist and knee radiographs were obtained for vitamin D-deficient participants. RESULTS The prevalence of vitamin D deficiency (< or =20 ng/mL) was 12.1% (44 of 365 participants), and 146 participants (40.0%) had levels below an accepted optimal threshold (< or =30 ng/mL). The prevalence did not vary between infants and toddlers or by skin pigmentation. There was an inverse correlation between serum 25OHD and parathyroid hormone levels (infants: r = -0.27, P < .001; toddlers: r = -0.20, P = .02). In multivariable models, breastfeeding without supplementation among infants and lower milk intake among toddlers were significant predictors of vitamin D deficiency. In vitamin D-deficient participants, 3 participants (7.5%) exhibited rachitic changes on radiographs, whereas 13 (32.5%) had evidence of demineralization. CONCLUSIONS Suboptimal vitamin D status is common among otherwise healthy young children. Predictors of vitamin D status vary in infants vs toddlers, information that is important to consider in the care of these young patients. One-third of vitamin D-deficient participants exhibited demineralization, highlighting the deleterious skeletal effects of this condition.