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Living Longer and Better: The Health Experience of California Seventh-day Adventists. Larry Beeson, DrPH Associate Professor School of Public Health Co-investigator,

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Presentation on theme: "Living Longer and Better: The Health Experience of California Seventh-day Adventists. Larry Beeson, DrPH Associate Professor School of Public Health Co-investigator,"— Presentation transcript:

1 Living Longer and Better: The Health Experience of California Seventh-day Adventists. Larry Beeson, DrPH Associate Professor School of Public Health Co-investigator, AHS-2

2 Adventist Health Study Background More than 95% of the half-trillion health care dollars ($500,000,000,000) in the U.S. each year goes to treat rather than prevent disease Issues in Science & Technology

3 Epidemiology: The study of the distribution (who, when, where) and causes (determinants) of health and disease in populations. Nutritional Epidemiology: The study of diet as promoting or preventing the onset of disease. Biomedical Research

4 Epidemiologic evidence suggests that choosing carefully and eating a well-balanced diet, you may reduce your cancer risk: 1. Eat a variety of foods every day 2. Include fresh fruits and vegetables, especially those high in vitamin A and C 3. Choose leafy green and yellow-orange vegetables 4. Keep intake of all fats low (both sat. & unsaturated) 5. Limit your use of butter, margarine, cream, shortening 6. Avoid hidden fats in salad dressing and snack foods 7. Choose lowfat or skim milk and lowfat cheeses 8. Choose fruit instead of high fat desserts

5 9. Eat foods with fiber for example: a) Whole grain breads b) Raw fruits and vegetables c) Beans, Peas, Seeds 10. Do not drink alcohol in excess 11. Do not smoke Cancer Prevention Public Health Service National Institutes of Health

6 Can we observe measurable health benefits in a people (e.g. SDAs) who have been practicing for more than 140 years the current recommendations of health-related organizations (ACS, AHA, CDC, NIH) ? Question

7 Adventist Literature “Animals are becoming more and more diseased, and it will not be long until animal food will be discarded by many besides Seventh-day Adventists … The Lord will teach many in all parts of the world to combine fruits, grains, and vegetables into foods that will sustain and will not bring disease.” 1902 - Vol 7, Testimonies, pg 124-6

8 Adventist Literature “Seventh-day Adventists are handling momentous truths. More than forty years ago [<1869] the Lord gave us special light on health reform, but how are we walking in that light? … On the subject of temperance we should be in advance of all other people.” 1909 - Vol 9, Testimonies, pg 158

9 Adventist Literature “In this age of the world the use of tobacco is almost universal. Women and children suffer from having to breathe the atmosphere that has been polluted by the pipe, the cigar, or … the tobacco-user. Those who live in this atmosphere will always be ailing.” 1882 - Vol 5, Testimonies, pg. 440

10 Adventist Literature “The liability to take disease is increased tenfold by meat eating.” 1868 - Vol 2, Testimonies, pg 64

11 Adventist Literature “Health is a treasure. Of all temporal possessions it is the most precious. Wealth, learning, and honor are dearly purchased at the loss of the vigor of health. None of these can secure happiness, if health is lacking.” 1890 - Christian Temperance and Bible Hygiene, pg 150

12 Adventist Literature “Fruits, grains, and vegetables, prepared in a simple way, free from spice and grease of all kinds, make … the most healthful diet.” 1870 - Vol 2, Testimonies, pg. 369

13 Adventist Literature “It is a mistake to suppose that muscular strength depends on the use of animal food. The needs of the system can be better supplied, and more vigorous health can be enjoyed, without its use.” 1905 - Ministry of Healing, pg. 316

14 Adventist Literature “Education in health principles was never more needed than now… Many transgress the laws of health through ignorance, and they need instruction. But the greater number know better than they do. They need to be impressed with the importance of making their knowledge a guide for life.” 1905 - Ministry of Healing, pg. 126

15 Seventh-day Adventists will continue to be a unique population for epidemiologic study 1. They are interested in health, hence cost effective postal contacts are likely to produce good response rates.

16 2. There are few subgroups in society that have the same range of exposures such as diet. This should increase statistical power in testing hypotheses.

17 3. The relative absence of cigarette smoking and alcohol consumption allow examination of the effects of other exposures (e.g. diet) without the potential confounding of tobacco and alcohol.

18 4. The church structure (i.e. “letters of transfer”) facilitates the tracking of subjects who move after initial enrollment in a study thus minimizing lost-to-followup.

19 5. Marked tendency towards vegetarianism makes this population probably the closest of any subgroup to the lifestyle recommendations of several official bodies seeking to prevent cancer and atherosclerotic vascular disease.

20 Research On Adventists by Loma Linda Epidemiologists 1. Adventist Mortality Study (1958 - 1985) 2. Adventist Health Study [ - 1] (1974 - 2006) 3. Adventist Health Study - 2 (2002 - future) 4. Adventist Health Study on Smog (AHSMOG) (1976 – future) 5. Adventist Health and Religion Study (AHRS) (2006 – future)

21 AHSMOG 1976-2006 6,328 SDA 25+ years California Adventist Health Studies U.S.A. 1958-2012 19661974 1950 201020001990198019701960 AMS 1958-1985 25,153 SDA 25+ years California AHS-1 1974-2006 34,198 SDA 25+ years California AHS-2 2002- 97,000 SDA 30+ years USA & Canada 12,000 overlap 5,649 overlap ARHS 2006- 11,000

22 Dietary Assessment Increasing Complexity Adventist Mortality Study (1958 - 1980) 4-page questionnaire n = 25,153 Adventist Health Study-1 (1974 - 2006) 20-page questionnaire n = 34,198 Adventist Health Study-2 (2002 - ????) 52-page questionnaire n = 97,000

23 www.llu.edu/public-health/health/index.page Adventist Health Study Home About the Study Enrollment Form Common Questions Progress of Enrollment News and Events Promotion Resources The Research Team Contact Us Previous Studies Selected references Bibliography Back

24 1.Hardinge MG, Stare FJ: Nutritional studies of vegetarians. I Nutritional, physical, and laboratory studies. Am J Clin Nutr 1954; 2:73-82. … 303. Fraser GE, Shavlik DJ. Ten years of life. Is it a matter of choice? Arch Int Med 2001;161:1645-52. 308. Chan J, Knutsen SMF, Blix GG, Lee JW, Fraser GE. Water, other fluids and fatal coronary heart disease: The Adventist Health Study. Am J Epidemiol 2002; 155:827-33. 313. Singh PN, Sabaté J, Fraser GE. Does low meat consumption increase life expectancy in humans? Am J Clin Nutrit 2003; 78(suppl):526S-32S. 315. Willett W. Lessons from dietary studies in Adventists and questions for the future. Am J Clin Nutr 2003; 78:539S-43S.

25 Oxford Univ. Press, 2003, pp 371 Available from Amazon.com

26 Areas with an unusual cluster of centenarians (age 100+): 1) Sardinia 2) Okinawa 3) Costa Rica 4) Loma Linda (only area in the United States) thanks to the AHS research team

27 Proportions of Life Table Subjects Surviving to Ages 65 Years and 85 Years. Percentage of males survivingPercentage of females surviving CountryTo Age 65 To Age 85 To Age 65 To Age 85 Australia74.717.686.438.4 Canada75.119.686.340.0 Germany, Fed. Rep.73.414.285.831.7 Hungary60.98.279.321.0 Japan80.823.689.541.1 Sweden78.720.488.439.8 United Kingdom75.014.584.632.7 United States72.019.584.139.3 California Adventist86.741.089.354.4 California Adventist Vegetarians 89.248.694.160.1

28 An Extra 10 Years of Life  Regular exercise  Eating plant-based diet  Eating small amounts of nuts regularly  Maintaining normal body weight  Not smoking Adventist Health Study-1 demonstrated that 5 simple habits Adventists have promoted for over 100 years extend their life by as much as 10 years in both men and women

29 Effects of Individual Risk Factors To Increase Life Expectancy VariableMenWomen Vegetarianism2.38 yrs1.65 yrs Vigorous Exercise2.14 yrs2.19 yrs Frequent Nut Consumption2.87 yrs1.18 yrs Avoid High BMI1.51 yrs1.90 yrs Never Smoked1.33 yrs1.49 yrs

30 Health Habits and Life Expectancy in Adventists MenWomen ‘Best’-Lifestyle 1 87.0 years88.5 years ‘Converse’-Lifestyle 2 76.2 years79.8 years Difference10.8 years8.7 years 1 Vegetarians who exercise vigorously at least 3 times weekly, eat nuts >4 times each week. BMI < 25.90 (males), <25.20 (females), never smokers. 2 Converse of the above, including eating nuts <1/week, BMI greater than limits shown above.

31 Life Expectancy at Age 30 years (1985). MenWomen Californians43.949.5 California Adventists51.253.9 Vegetarian Adventists53.355.7 Extra Years California Adventists7.34.4 Vegetarian Adventists9.46.2

32 Different Types of ‘Vegetarians’ 1.Lacto-Ovo-vegetarians 2.Fish-eating (pesco) ‘vegetarians’. 3.High and low processed food vegetarians. 4. Soy and non-soy vegetarians. 5. Vegans and Fruitarians. High lacto Low lacto

33

34 1) Measures of association between exposure and health outcome:  “Relative Risk” = “Risk Ratio” = “RR” 2) Statistical significance  Biologic significance ??  “p-value” Brief Introduction to Epidemiology

35 The Relative Risk (RR) Incidence of disease (in those “exposed”) Incidence of disease (in those “not exposed”) RR = If: RR is less than (<) 1, then exposure is reduces risk of disease If: RR is equal to (=) 1, then exposure is unrelated to disease If: RR is greater than (>) 1, then exposure increases risk of disease High Low or

36 Statistical Significance: (p-value) p (probability)-value: The probability that an observed value from a statistical test (e.g. RR) could have occurred by chance, if the comparison groups were really alike. In biomedical research (i.e. Epidemiology), we traditional say that if the p-value is less than (<) 5%, then another explanation (e.g. biology) is a better explanation of the observation than is chance alone.

37 Percentages Dying From the Named Causes and Average Ages at these Fatal Events: California non-Adventists and Adventists. All CaliforniansAll Adventists Men Cause of Death (%) %Age (Years) % Disease of the Heart39.075.740.482.9 Malignant Neoplasms (Cancer)23.471.219.077.9 Cerebrovascular Disease (Stroke)6.679.48.785.8 Unintentional Injuries2.959.53.569.6 COPD and Allied Conditions5.676.32.582.6 Pneumonia and Influenza4.581.86.187.8 Diabetes1.173.01.381.6 p<0.05; p<0.01; p<0.001

38 Life Expectancy Given Survival to Different Ages. California Adventists (1980-88) and Other Californians (1985). AgeAdventistCaliforniaDifference 3051.1543.877.28 5032.2525.966.29 7015.1411.713.43 904.694.530.16 Men AgeAdventistCaliforniaDifference 3053.9449.524.42 5034.7230.714.01 7017.5214.812.71 905.355.020.33 Women

39 Effect of meat.

40 Meat intake and risk of different cancers. Colon Prostate Ovary Ovary Postmenopausal P (t): 0.01 ns <.01 0.02 RR

41 Total meat intake and risk of colon cancer Never < 1/week 1+/week P (trend)=0.01 (0.92-2.45) (1.16-2.87) RR

42 Red meat intake and risk of colon cancer, among those who eat white meat < 1x/week. Never < 1/week 1+/week P (trend) = 0.02 (0.87-2.25) (1.16-3.11) RR

43 White meat intake and risk of colon cancer, among those who eat red meat < 1x/week. Never < 1/week 1+/week P (trend) = 0.006 (0.97-2.50) (1.60-6.75) RR

44 Meat Consumption and Cancer Meat Frequency Cancer SiteNever<1/week>1/weekp values Colon1.001.501.85.01 Prostate1.001.151.41NS* Ovary1.001.391.75<0.10 (Postmenopausal)1.001.592.300.02 <3/week>3/week Bladder1.002.380.01 * Not statistically significant

45 Nut Consumption and Coronary Heart Disease FatalDefinite Non-Fatal MI Relative Risk P(t) <.001 P<.001 P(t) <.001 P<.001

46 Nut Consumption and Coronary Heart Disease Events 66 85 33 66 85 33 MenWomen Relative Risk P(t) <.001 P<.001 P(t) <.001 P<.001

47 Nut Consumption and Coronary Heart Disease Events 63 55 15 79 76 57 NonVegetarians Vegetarians Relative Risk P(t) <.05 P<.05 P(t) <.001 P<.001

48 Nut Consumption and Coronary Heart Disease Events 65 85 34 77 47 38 Age <80 Age 80+ Relative Risk P(t) <.05 P<.05 P(t) <.001 P<.001

49 RR ‡ of F ATAL CHD according to Intake of W ATER in M ALES (n=11,257) ‡ Adustments: Age + Smoking, Ed, + Energy + Other BMI, BP Fluids BMI, BP Fluids Relative Risk Events 25 51 48 24 34 37 22 42 33 17 33 23.001.0002.0004.0003 p (trend) Glasses/day

50 RR ‡ of F ATAL CHD according to Intake of W ATER in F EMALES (n=15,840) ‡ Adustments: Age + Smoking, Ed, + Energy + Other BMI, BP Fluids BMI, BP Fluids Relative Risk Events 23 40 52 18 34 43 13 17 26 13 17 26 p(trends) NS Glasses/day

51 RR ‡ of F ATAL CHD according to W ATER I NTAKE Males & Females ( n= 27,342 ) RR ‡ of F ATAL CHD according to W ATER I NTAKE Males & Females ( n= 27,342 ) RR Events 28 50 60 20 40 41 Glasses/day Normotensive Hypertensive <.01 <.05 p (trend) Age & Sex Adjusted

52 RR ‡ of FATAL CHD according to WATER INTAKE Males & Females ( n= 27,342 ) RR Events 23 52 58 24 35 37 Glasses/day Meat <1/week Meat 1+/week.003.02 p (trend) Age & Sex Adjusted

53 RR ‡ of F ATAL STROKE according to WATER Intake in M & F with Stroke Hx (n=614) ‡ Adj: ( Age & Sex) (+ BP, Smoking, (+ Ex ( + Other) Fl BMI) or Diab) BMI) or Diab) Relative Risk Events 15 37 27 15 28 21 13 26 21 9 20 14 <.05 <.01 <.02.08 p (trend) Servings /day

54 Whole Grain or White Bread and Coronary Heart Disease Relative Risk

55 Relative Risk of fatal CHD according to Exercise Status Age & Sex Adjusted (Adventist Mortality and Adventist Health Studies) Relative Risk

56 Other diseases in Adventists: Vegetarians vs Nonvegetarians.

57 Weight Differences Between Vegetarians and Non-Vegetarians Pounds = FemaleMale 0 146 161 193 181 188 177 161 180 164 171

58 DIABETES Prevalence and diet patterns.

59 Frequency of Type 2 Diabetes by Dietary Status and Race

60 Associations between Vegetarian Status and the Prevalence of Diabetes in Adventists MENWOMEN Vegetarian Status Adjusted for Age and BMI 95% Confidence Interval Adjusted for Age and BMI 95% Confidence Interval Vegetarian1.00 Semivegetarian1.290.97-1.710.980.80-1.20 Nonvegetarian 1.72***1.36-2.19 1.60***1.36-1.88 *** p<.0001

61 ARTHRITIS Prevalence and diet patterns.

62 Risk of prevalent rheumatoid arthritis and meat intake. Females. 1.49 (1.31-1.7) # Adjusted for age, BMI, education, oral contraceptive use, number of live births, smoking and alcohol intake. 1.26 (1.21-1.43) Meat intake: Never < 1x /wk 1+ /wk

63 Risk of prevalent rheumatoid arthritis and meat intake. Males. 1.43 (1.20-1.7) # Adjusted for age, BMI, education, number of live births, smoking and alcohol intake. 1.19 (1.05-1.34) Meat intake: Never < 1x /wk 1+ /wk

64 Selected Risk Factors in Adventists: Vegetarians vs Nonvegetarians.

65 Frequency of Hypertension by Dietary Status and Race

66 Relative Risk of Incidence of HYPERTENSION Requiring Medication (1960-76) according to Vegetarian Status (Adventist Mortality and Adventist Health Studies) All values significant. Relative Risk

67 Associations between Vegetarian Status and the Prevalence of Hypertension in Adventists. MenWomen Vegetarian StatusAdjusted for Age and BMI 95% Confidence Interval Adjusted for Age and BMI 95% Confidence Interval Vegetarian1.00 Semivegetarian1.661.34-2.071.501.30-1.73 Nonvegetarian2.261.87-2.732.312.04-2.61

68 Frequency of High Cholesterol by Dietary Status and Race

69 Fruits and vegetables

70 Fruit and Cancer Cancer Site Fruit Types Frequency Relative Risk OvaryAll fruits <5/wk 1.00 1-2/day 1.24 >2/day 0.59 PancreasRaisins, dates, dried fruit <1/month 1.00 > 3/wk 0.19 ProstateRaisins, dates, dried fruit <1/wk 1.00 1-4/wk 1.17 > 5/wk 0.62 LungAll fruits <3/wk 1.00 3-7/wk 0.30 >1/day 0.26

71 SOY MILK

72 Soy Foods 1.Reduces cholesterol 2.Isoflavone phytoestrogens (Genistein, daidzein, equol) 3. May affect risk of cancers, heart disease, osteoporosis, and other disorders 4. American Adventists consume a great deal of soy as a non-meat complete protein

73 Relative risk* of prostate cancer by intake of soy milk. P(t) =.02 *Adjusted for age, BMI, consumption of coffee, whole milk, eggs and citrus fruit and age at first marriage. *Adjusted for age, BMI, consumption of coffee, whole milk, eggs and citrus fruit and age at first marriage. Jacobsen et al, (0.5-1.4) Never < daily 1 x/day 2+ day # men 10,875 902 395 223 (0.4-1.4) (0.1-0.9)

74 Tomatoes and Cancer TomatoFrequency Cancer Site<1/week1-4/week>5/weekp values Prostate1.000.640.60.10 Ovary1.000.720.32.001

75 Fruit and Cancer Cancer Site Fruit Types ( Fruit Frequencies)/Risk Ratios OvaryAll fruits(<5/wk) 1.00; (1-2/day)1.24; (>2/day) 0.59 PancreasRaisins, dates, dried fruit ( 3/wk) 0.19 ProstateRaisins, dates, dried fruit (<1/wk) 1.00; (1-4/wk) 1.17; (> 5/wk) 0.62 LungAll fruits(<3/wk) 1.00; (3-7/wk) 0.30; (>1/day) 0.26

76 The Independent Effects of Traditional Lifestyle Risk Factors and Psychosocial and Religious Participation Variables on Coronary Heart Disease (CHD) Mortality in California Adventists ALL VARIABLES VariableLevelMenWomenCombined GenderWomen Men 1.00 1.63*** MeatVegetarian <1/wk >1/wk 1.00 1.56** 1.59** 1.00 1.18 1.03 1.00 1.31** 1.21** ExerciseLow Medium High 1.00 0.86 0.70** 1.00 0.84 0.73** 1.00 0.85 0.71*** Nuts<1/wk 1-4/wk >5/wk 1.00 1.04 0.85 1.00 0.77* 0.68** 1.00 0.87 0.73** SmokingNever Past 1.00 1.04 1.00 1.09 1.00 1.04 Church Attendance3-4/mo 1-2/mo <1/mo 1.00 0.76 1.55 1.00 1.70 1.38 1.00 1.23 1.58** **p<0.01 *** p<0.001

77 The Independent Effects of Traditional Lifestyle Risk Factors and Psychosocial and Religious Participation Variables on All-Cause Mortality in California Adventists ALL VARIABLES VariableLevelMenWomenCombined SexWomen Men 1.00 1.50*** MeatVegetarian <1/wk >1/wk 1.00 0.99 1.09 1.00 1.02 1.08 1.00 1.01 1.09* ExerciseLow Medium High 1.00 0.80*** 0.75*** 1.00 0.81*** 1.00 0.81*** 0.79*** Nuts<1/wk 1-4/wk >5/wk 1.00 0.87* 0.78*** 1.00 0.89** 0.88** 1.00 0.89*** 0.84*** SmokingNever Past 1.00 1.09* 1.00 1.15* 1.00 1.13** Church Attendance3-4/mo 1-2/mo <1/mo 1.00 0.99 1.32* 1.00 1.20 1.17 1.00 1.12 1.25** *p<0.05 **p<0.01 ***p<0.001

78 Meat seems to be one of the “villains” associated with Coronary Heart Disease (CHD) Colon cancer Bladder cancer Ovarian cancer

79 Other Foods with Probable preventive action for CHD and or Cancer Fruit Legumes Soy Whole grains Nuts Tomatoes ? Cruciferous Vegetables

80 Summary 1.As a group, risk of CHD is much lower in Adventists but this is especially so below the age of 70 years. 2.Risk of many cancers is also much lower, and this is not all explained by the absence of cigarette smoking in Adventists. 3.Adventist men and women in California live much longer that other Californians, this being especially true of the vegetarians. 4.Adventists often have unusual dietary habits that trend toward vegetarianism. 5.Age at virtually all common causes of death is greater by several years.

81 Summary Cont’d 6. Individual foods that change risk are technically difficult to identify, but the following are probable associations. a) Nuts, and whole grain bread consumption decrease risk of coronary heart disease (CHD). b) Meat consumption probably increases risk of CHD particularly in younger and middle-aged subjects. c) Fruits, legumes (including soy-products), and tomatoes probably decrease risk of several cancers. d) Meat consumption probably increases risk of colon, ovary, bladder and perhaps other cancers. e) This list by no means exhausts the possibilities.

82 CONCLUSION The studies on Adventists in California suggest that a vegetarian lifestyle reduces the risk of many chronic diseases such as: CHD Cancer Obesity Arthritis Diabetes

83 Summary AHS “Firsts” 1. The AHS was the first epidemiologic study to demonstrate that men who consumed tomatoes & tomato products frequently, importantly reduced their risk of prostate cancer. (Is it licopenes alone or the complexity of the food ???)

84 Summary AHS “Firsts” 2. The AHS was the first study to demonstrate that eating nuts 5 or more times per week appears to significantly reduce the risk of definite fatal CHD and definite nonfatal myocardial infarction compared to eating nuts less than once a week. Similar findings were seen for eating whole wheat bread.

85 Summary AHS “Firsts” 3. AHS was the first to demonstrate that intake of adequate amounts of water each day may significantly reduce the risk of fatal coronary heart disease (CHD). This observed protection in both males and females was independent of other established CHD risk factors.

86 Summary 4. Those who consume a wide range of fruits, vegetables, seeds, whole grains, and nuts have less disease than those who follow a typical American diet.

87 Summary 5. Vegetarians appear to be at lower risk than omnivores for several fatal chronic diseases: a) Cancers of the colon, breast, prostate b) Cardiovascular disease c) Diabetes

88 Summary 6. Vegetarians have more favorable heart disease risk profiles: a) Decreased blood pressure b) Decreased serum cholesterol c) Decreased prevalence of obesity

89 Summary 7. Cancer risk may be lower because of several factors: a) Increased plant sterol/cholesterol ratio in the diet b) Decreased primary/secondary bile acids ratio c) Favorable dietary factors, including more fiber and less fat

90 Our Oldest Old 1,765 - aged 90 years + 99 - over 100 years Lydia Newton 112 years

91 Our Centenarians Marge Jetton 101 (turned 105 on 9/29/09) Marguerite 90, Lydia 112 (Lydia’s daughter)

92 Description of the AHS-1 Study Beeson WL, Mills PK, Phillips RL, Andress M, Fraser GE: Chronic disease among Seventh-day Adventists, A low risk group. Rationale, Methodology and description of the population. Cancer 1989;64:570-581. Description of the AHS-2 Study Butler TL, Fraser GE, Beeson WL, Knutsen SF, Herring RP, Chan J, Sabate J, Montgomery S, Haddad E, Preston-Martin S, Bennett H, Jaceldo-Siegl K. Cohort profile: The Adventist Health Study-2 (AHS-2). Int J Epidemiol 2007; Aug 27: [Epub ahead of print]

93 THANK YOU! And for those who answered our AHS questionnaires as your voice is being heard around the world ! www.llu.edu/public-health/health/index.page (AHS web page)


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