John B. McKinlay

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.

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.

Some approaches and problems in the study of the use of services: an overview.

A selective systematic overview is provided of the literature on the utilization of health and welfare services that appeared in the United States and Europe mainly within the last two decades. Methodological questions that appear to characterize much of the work to date are discussed and analytically distinct approaches or research strategies in the study of utilization behavior are presented. The paper traces the emergence of work in this area questions the wisdom of investigators proceeding along traditional research lines and highlights a number of promising new possibilities for research. (authors)

An examination of research design effects on the association of testosterone and male aging: Results of a meta-analysis

The study of testosterone is likely to be prominent in future epidemiological work on endocrine function and the clinical treatment of age-related diseases. Thus, understanding the hormonal changes involved in the normal male aging process will be critical. Using techniques of meta-analysis, the authors examined 88 published studies of the age-testosterone relation in men. These studies reported conflicting results: age-testosterone correlations ranged from -0.68 to +0.68. In cross-study comparisons, certain research design characteristics (e.g. time of day of blood sampling) and various sample characteristics (e.g. volunteers vs patients as subjects) were related to both mean testosterone level and the slope of the age-testosterone relation. For example, for subgroups of subjects that did not exclude ill men, the mean testosterone levels were low, and did not decline with age. Subgroups that included only healthy subjects, in contrast, had higher overall testosterone levels and showed a decline of testosterone with age. Implications of these results for design, analysis and reporting of future epidemiologic studies will be discussed. These results also illustrate the utility of meta-analysis for research with the aged.

Smoking and age at menopause in women.

Although women can expect to live one half of their adult lives beyond menopause, knowledge about this physiologic event and its various influences on subsequent health and quality of life remains incomplete. In Massachusetts we studied a population-based random sample of 7828 white women, aged 45 to 55 years (response rate, 77%). The median age at last menstruation for the sample is 51.4 +/- 0.19 (SE) years years, and we found no evidence of a secular trend towards a later age at menopause in the last 25 years. Current smokers reach menopause an average of 1.74 years earlier than nonsmokers (t = 3.78, p less than 0.01), but the quantity smoked has a negligible effect. Other potential correlates measured--education and marital status, number of children, and urban/rural residence--have little effect on the age at menopause. The results confirm earlier, more tentative findings from clinical populations.

Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men

We defined risk factors for a clinical diagnosis of benign prostatic hyperplasia (BPH) among subjects of the population-based Massachusetts Male Aging Study. In 1987-89 1709 men aged 40-70 provided baseline risk factor data and were followed for a mean of 9 years; 1019 men without prostate cancer provided follow-up data. We classified men with clinical BPH at follow-up if they reported (1) frequent or difficulty urinating and were told by a health professional that they had an enlarged or swollen prostate or (2) if they reported having surgery for BPH. At follow-up the prevalence of clinical BPH was 19.4%, increasing from 8.4% of men aged 38-49 years to 33.5% of men aged 60-70 years (P < 0.001 for trend). Elevated free PSA levels (age- and total PSA-adjusted OR, top vs. bottom quartile ng/mL 4.4, 95% CI 1.9-10.5), heart disease (age-adjusted OR 2.1, CI 1.3-3.3), and use of beta-blocker medications (OR 1.8, CI 1.1-3.0) increased odds for BPH, while current cigarette smoking (OR 0.5, CI 0.3-0.8) and high levels of physical activity (top vs. bottom quartile kcals/day OR 0.5, CI 0.3-0.9) decreased odds of BPH. All but the medication effects persisted in fully adjusted multivariable models. Total or fat calorie intake, sexual activity level, alcohol intake, body mass index, waist-hip ratio, diastolic blood pressure, a history of diabetes, hypertension, vasectomy, or serum levels of androgens or estrogens did not individually predict clinical BPH. We conclude that physical exercise and cigarette smoking appear to protect against development of clinical BPH. Elevated free PSA levels predict clinical BPH independent of total PSA levels. Risk associated with heart disease does not appear to be due solely to detection bias or to effects of heart disease medications. A wide variety of other characteristics appear to have no influence on risk for clinical BPH.

The relative contributions of endocrine changes and social circumstances to depression in mid-aged women

Although researched extensively over several decades, the prevalence, costs and reasons for depression among women during the middle years remain a challenge to public health. A vast literature is distilled into two predominant schools of thought, each with profoundly different implications for research and clinical practice. One school (the estrogen-deficiency perspective) holds that depression is associated with or triggered by endocrine changes in women around 50 years of age (menopause). A second school (the social-circumstances perspective) holds that depression is related to social circumstances encountered frequently by women during their fourth and fifth decades. Employing data from a randomly selected cohort of 2,500 premenopausal women sampled in Massachusetts, this paper shows that: * depression is associated with a surgical menopause and may even be a cause rather than a consequence of this surgery for this atypical group of women; * depression is not associated with the natural changes from preto immediately postmenopause; and * the most marked increases in depression are associated with multiple causes of worry and multiple roles among currently married women (including paid work, adolescent children, ailing husbands, and aging parents or parents-in-law). Some implications of these findings are discussed in the context of a rapidly aging population.

Body mass index, waist circumference and waist to hip ratio and change in sex steroid hormones: the Massachusetts Male Ageing Study.

Objective  Cross‐sectional data suggest that obesity, particularly central obesity, may be associated with decreased production of sex steroid hormones in men. However, longitudinal hormone data on men in relation to obesity status are limited. Previous studies have not consistently demonstrated whether sex steroids are associated specifically to body mass index or to measures of central obesity. Our objective was to examine the relation of obesity (body mass index > 30 kg/m2), and of central obesity (waist circumference > 100 cm or waist to hip ratio > 0·95) to longitudinal change in sex steroid hormones in men.