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UBC Theses and Dissertations

The relationship of nutritional practices and related demographic variables Scott, Elaine Marion 1976

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THE RELATIONSHIP OF NUTRITIONAL PRACTICES AND RELATED DEMOGRAPHIC VARIABLES TO THE PRESENCE OF HYPERLIPOPROTEINEMIA by ELAINE MARION SCOTT Dip. H.Sc., U n i v e r s i t y of Otago, New Zealand, 1964 R e g i s t e r e d D i e t i t i a n , New Zealand, 1965 ,H'.E., U n i v e r s i t y o f B r i t i s h Columbia, Vancouver, 1974 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n the D i v i s i o n of HUMAN NUTRITION SCHOOL OF HOME ECONOMICS We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA February, 1976 © E l a i n e Marion S c o t t , 1976 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced deg ree at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r ee t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r ag ree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y pu rpo se s may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f WoHg ^ Co M O M ( CS The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date Afle/l 3 19% ABSTRACT At the present time, c a r d i o v a s c u l a r d i s e a s e i s a major p u b l i c h e a l t h problem i n Canada, t a k i n g the l i v e s of 78,000 Canadians each y e a r . One of the important r i s k f a c t o r s i m p l i c a t e d i n the p a t h o p h y s i o l o g y o f c a r d i o v a s c u l a r d i s e a s e i s h y p e r l i p o p r o t e i n e m i a . F a c t o r s which have been i m p l i c a t e d i n the e t i o l o g y of h y p e r l i p o p r o t e i n e m i a i n c l u d e n u t r i t i o n a l p r a c t i c e s and r e l a t e d demographic v a r i a b l e s such as excess body weight, l a c k o f p h y s i c a l a c t i v i t y , smoking, a l c o h o l consumption, abnormal carbohydrate metabo-l i s m and f a m i l y h i s t o r y of h eart d i s e a s e . Although a l l of the f a c t o r s c i t e d here have been i n v e s t i g a t e d and t h e i r r o l e i n the development of h y p e r l i -p o p r o t e i n e m i a r e p o r t e d i n the l i t e r a t u r e , the importance of the i n t e r r e l a t i o n s h i p among the i n d i v i d u a l f a c t o r s has f r e q u e n t l y been o v e r l o o k e d . A l s o the r e l a t i o n s h i p of these f a c t o r s to the presence of h y p e r l i p o p r o t e i n e m i a i n many cases i s p o o r l y understood. A study was designed t o i n v e s t i g a t e the r e l a t i o n s h i p of n u t r i t i o n a l p r a c t i c e s and r e l a t e d demographic v a r i a b l e s to the presence o f h y p e r l i p o p r o t e i n e m i a i n males aged t h i r t y t o s i x t y y e ars who were admitted to St. P a u l ' s H o s p i t a l , Vancouver, B r i t i s h Columbia, f o r c a r d i a c c a t h e t e r i z a t i o n . The c r i t e r i o n v a r i a b l e s measured i n the study were the f a s t i n g serum t r i g l y c e r i d e l e v e l and f a s t i n g serum c h o l e s t e r o l l e v e l . The v a r i a t e s were c a t e g o r i z e d as n u t r i t i o n a l p r a c t i c e s , demographic f a c t o r s and anthropometric measurements. N u t r i t i o n a l p r a c t i c e s i n c l u d e d sucrose as percent o f t o t a l c a r bohydrate, s t a r c h as percent o f carbohydrate, P:S r a t i o , t o t a l c a l o r i c i n t a k e , f a t as percent of t o t a l c a l o r i e s and a l c o h o l as percent o f t o t a l c a l o r i e s . The nature o f the r e l a t i o n s h i p between the c r i t e r i o n v a r i a b l e s and the v a r i a t e s , and amongst the v a r i a t e s themselves, were i n v e s t i g a t e d . R e s u l t s are based on i n t e r v i e w s conducted w i t h 64 sub-j e c t s between March 1 and October 16, 1975. S i x t y - f o u r percent o f the s u b j e c t s e x h i b i t e d a serum t r i g l y c e r i d e l e v e l beyond the range accepted as normal by S t . Pa u l ' s H o s p i t a l l a b o r a t o r y w h i l e o n l y 3% had abnormally h i g h serum c h o l e s t e r o l l e v e l s . The Pearson product moment c o r r e l a t i o n c o e f f i c i e n t r e v e a l e d a s i g n i f i c a n t c o r r e l a t i o n between the serum t r i g l y -c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n s at the 0.002 l e v e l of s i g n i f i c a n c e . A n a l y s i s of t - d i s t r i b u t i o n showed no s i g n i f i c a n t c o r r e -l a t i o n between the presence of h y p e r l i p o p r o t e i n e m i a and the consumption of suc r o s e as percent o f t o t a l c a r b o h y d r a t e , s t a r c h as percent o f t o t a l c arbohydrate, f a t as per c e n t of t o t a l c a l o r i e s , a l c o h o l as percent o f t o t a l c a l o r i e s o r P:S r a t i o . S i m i l a r l y , the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t f a i l e d t o show a s i g n i f i c a n t c o r r e l a t i o n between c a l o r i c i n t a k e and the presence o f h y p e r l i p o p r o t e i n e m i a at the 0.05 l e v e l o f s i g n i f i c a n c e . However, both p h y s i c a l i i i a c t i v i t y and ponderal index were s i g n i f i c a n t factors by t - t e s t analysis, i n d i c a t i n g the r e l a t i o n s h i p of both over-weight and i n a c t i v i t y to the presence of hyperlipoproteinemia. In addition, c o r r e l a t i o n analysis revealed a p o s i t i v e corre-l a t i o n between f a s t i n g blood glucose and the presence of hyperlipoproteinemia. No c o r r e l a t i o n was observed with age or smoking and the presence of hyperlipoproteinemia. Implications r e l a t i v e to evaluation of the atherogenic status of an i n d i v i d u a l and possible reduction of the i n c i -dence of hyperlipoproteinemia became apparent from the i n t e r -pretation of the findings of t h i s study. i v TABLE OF CONTENTS ABSTRACT LIST OF TABLES LIST OF FIGURES ACKNOWLEDGEMENTS Chapter I . INTRODUCTION 1 Background and Need 1 Statement o f the Problem . . 4 Hypotheses 6 D e f i n i t i o n of Terms. . 7 Assumptions 7 O r g a n i z a t i o n o f the Study 8 I I . REVIEW OF THE LITERATURE 9 C l a s s i f i c a t i o n o f H y p e r l i p o p r o t e i n e m i a . 10 C r i t e r i o n V a r i a b l e s 15 V a r i a t e s 16 N u t r i t i o n a l P r a c t i c e s 16 D i e t a r y carbohydrate 16 D i e t a r y L i p i d s 20 T o t a l C a l o r i e s 23 A l c o h o l i n t a k e 25 Demographic F a c t o r s 27 Smoking 27 P h y s i c a l e x e r c i s e 29 Family h i s t o r y o f he a r t d i s e a s e . . . 34 Drugs 35 Age 36 Glucose i n t o l e r a n c e 37 Anthropometry 39 Methodology f o r Assessment o f N u t r i t i o n a l P r a c t i c e s and Anthropometric Status . . 40 Anthropometry S t a t u s . 40 N u t r i t i o n a l P r a c t i c e s 42 Summary 45 i i . v i i i x x i v I I I . DESIGN OF THE STUDY 48 Research Design 48 P o p u l a t i o n and Sample 50 Data C o l l e c t i o n 50 N u t r i t i o n a l P r a c t i c e s 50 Demographic F a c t o r s 53 Anthropometry 54 C r i t e r i o n V a r i a b l e s . . . 55 F a s t i n g serum t r i g l y c e r i d e l e v e l . . 55 F a s t i n g serum c h o l e s t e r o l l e v e l . . 55 Procedure 55 Schedule 56 Data A n a l y s i s . . . 57 IV. FINDINGS AND INTERPRETATIONS. . . . . . . 60 C r i t e r i o n V a r i a b l e s 60 T r i g l y c e r i d e s 60 C h o l e s t e r o l 63 V a r i a t e s 64 N u t r i t i o n a l P r a c t i c e s . . . . . . . . 64 Demographic F a c t o r s 70 Anthropometry 74 R e l a t i o n s h i p Between the C r i t e r i o n V a r i a b l e s 76 R e l a t i o n s h i p s Among the V a r i a t e s . . . . 77 R e l a t i o n s h i p s Between the C r i t e r i o n V a r i a b l e s and the V a r i a t e s 80 A n a l y s i s of R e l a t i o n s h i p of S e l e c t e d V a r i a t e s to the Presence of Hyper-l i p o p r o t e i n e m i a 82 A n a l y s i s o f the R e l a t i o n s h i p o f S e l e c t e d V a r i a t e s to the I n d i v i d u a l C r i t e r i o n V a r i a b l e s 89 M u l t i v a r i a t e A n a l y s i s of the R e l a t i o n -s h i p Between the V a r i a t e s and the Presence of H y p e r l i p o p r o t e i n e m i a . . 96 M u l t i p l e R e g r e s s i o n A n a l y s i s of the R e l a t i o n s h i p o f S e l e c t e d V a r i a t e Combinations to the I n d i v i d u a l C r i t e r i o n V a r i a b l e s 101 L i m i t a t i o n s o f the Study 105 V. SUMMARY AND IMPLICATIONS 107 Summary 107 I m p l i c a t i o n s 115 v i LITERATURE CITED 119 APPENDICES A. Data C o l l e c t i o n Instruments 130 B. Sucrose and S t a r c h E s t i m a t i o n s 142 C. Scattergrams Showing R e l a t i o n s h i p o f S e l e c t e d V a r i a t e s t o the I n d i v i d u a l C r i t e r i o n V a r i a b l e s 144 v i i LIST OF TABLES I. S c o r i n g system f o r p h y s i c a l a c t i v i t y 53 I I . Mean and Standard D e v i a t i o n f o r V a r i a b l e s Observed i n the Study 61 I I I . F a s t i n g Serum T r i g l y c e r i d e L e v e l s of P a r t i c i p a n t s 62 IV. F a s t i n g Serum C h o l e s t e r o l L e v e l s o f P a r t i c i p a n t s 63 V. Carbohydrate Consumption of P a r t i c i p a n t s . . . 65 VI. Sucrose Consumption of P a r t i c i p a n t s 66 V I I . S t a r c h Consumption of P a r t i c i p a n t s 66 V I I I . Fat Consumption o f P a r t i c i p a n t s 67 IX. F a t t y A c i d Consumption of P a r t i c i p a n t s . . . . 68 X. C a l o r i c Consumption of P a r t i c i p a n t s . . . . . . 68 XI. A l c o h o l Consumption of P a r t i c i p a n t s 69 X I I . D i s t r i b u t i o n o f the D i e t a r y Data C o l l e c t i o n Methods Used . . . . . 70 X I I I . D i s t r i b u t i o n o f P a r t i c i p a n t s by C i g a r e t t e Smoking H a b i t s 71 XIV. D i s t r i b u t i o n of P a r t i c i p a n t s by P h y s i c a l A c t i v i t y Score 72 XV, D i s t r i b u t i o n of P a r t i c i p a n t s by Age 73 XVI. F a s t i n g Blood Glucose L e v e l s o f P a r t i c i p a n t s . 74 XVII. He i g h t , Weight and Pon d e r a l Index of P a r t i c i p a n t s 75 XV I I I . Arm Circumference and T r i c e p S k i n f o l d T h i c k n e s s o f P a r t i c i p a n t s 76 XIX. Pearson Product Moment C o r r e l a t i o n C o e f f i c i e n t o f the C r i t e r i o n V a r i a b l e s . . . . 77 v i i i XX. Pearson Product Moment C o r r e l a t i o n C o e f f i c i e n t s of S e l e c t e d V a r i a t e s 78 XXI. Serum T r i g l y c e r i d e and C h o l e s t e r o l C o n c e n t r a t i o n s Reported as a Dichotomous V a r i a b l e 81 XXII. D i s t r i b u t i o n of P a r t i c i p a n t s by T r i g l y c e r i d e and C h o l e s t e r o l C o n c e n t r a t i o n s 82 XXIII. T - D i s t r i b u t i o n o f the R e l a t i o n s h i p of S e l e c t e d V a r i a t e s to the Presence of H y p e r l i p o p r o t e i n e m i a 83 XXIV. Pearson Product Moment C o r r e l a t i o n C o e f f i c i e n t s f o r S e l e c t e d V a r i a t e s and the C r i t e r i o n V a r i a b l e s 90 XXV. T r i g l y c e r i d e C o n c e n t r a t i o n of Non-smokers, Ex-smokers and Smokers 9S XXVI. C h o l e s t e r o l C o n c e n t r a t i o n o f Non-smokers, Ex-smokers and Smokers 95 XXVII. C a n o n i c a l C o r r e l a t i o n s I n d i c a t i n g the R e l a t i o n s h i p Between S e l e c t e d Combinations of the V a r i a t e s and the C r i t e r i o n V a r i a b l e s 96 XXVIII. M u l t i p l e R e g r e s s i o n A n a l y s i s Showing R e l a t i o n s h i p Between S e l e c t e d V a r i a t e s and the Serum T r i g l y c e r i d e C o n c e n t r a t i o n . . . . 102 XXIX. M u l t i p l e R e g r e s s i o n A n a l y s i s Showing R e l a t i o n s h i p Between S e l e c t e d V a r i a t e s and the Serum C h o l e s t e r o l C o n c e n t r a t i o n . . . . 104 i x LIST OF FIGURES 1. The nature of the r e l a t i o n s h i p between the c r i t e r i o n v a r i a b l e s and the v a r i a t e s and amongst the' v a r i a t e s themselves 49 2. Data c o l l e c t i o n model 51 x ACKNOWLEDGEMENTS The author would l i k e to express s i n c e r e a p p r e c i a t i o n to her major a d v i s o r , Dr. Nancy Schwartz, f o r her support and enthusiasm d u r i n g the p e r i o d o f graduate study and f o r her expert guidance i n the development of t h i s t h e s i s . Dr. A r t h u r Dodek, a member o f the t h e s i s committee, i s g r a t e f u l l y acknowledged f o r h i s i n t e r e s t and a s s i s t a n c e d u r i n g the p l a n n i n g s t a g e s o f the study and p r e p a r a t i o n of t h i s r e p o r t . The t h i r d member of the committee, Dr. K Damji, i s a l s o acknowledged f o r her a s s i s t a n c e i n the p r e p a r a t i o n o f t h i s r e p o r t . S i n c e r e thanks are extended t o Dr.'s J Boone, A Dodek, D. Kavanagh-Gray and D. P e r e t z f o r extendin g p e r m i s s i o n t o the r e s e a r c h e r to i n t e r v i e w t h e i r p a t i e n t s ; to V i r g i n i a Green f o r computer programming and s t a t i s t i c a l a n a l y s i s of the data; t o Warren Mayo f o r h i s encouragement, c r i t i c i s m and su g g e s t i o n s ; and to H i l d a Mayo f o r t y p i n g t h i s t h e s i s . Above a l l , the author would l i k e t o thank her p a r e n t s , Hughie and Marion S c o t t , whose u n s e l f i s h n e s s , hard work and encouragement made her e d u c a t i o n p o s s i b l e . x i CHAPTER 1 INTRODUCTION Background and Need At the present time, c a r d i o v a s c u l a r d i s e a s e i s a major p u b l i c h e a l t h problem i n Canada, t a k i n g the l i v e s of 78,000 Canadians each year ( B r i t i s h Columbia Heart F o u n d a t i o n ) . One of the important r i s k f a c t o r s i m p l i c a t e d i n the patho-p h y s i o l o g y of c a r d i o v a s c u l a r d i s e a s e i s h y p e r l i p o p r o t e i n e m i a (Commentary, P e d i a t r i c s , 1974). It has been suggested t h a t the l i f e - s t y l e i n c i v i l i z e d c o u n t r i e s c o n t r i b u t e s to the development of h y p e r l i p o p r o t e i n -emia . . . . o v e r e a t i n g , improper d i e t , empty c a l o r i e s , l a c k of e x e r c i s e , o b e s i t y , d i a b e t e s , h y p e r t e n s i o n and smoking ...have a l l been i m p l i c a t e d ( A l b r i n k , 1974). H y p e r l i p o p r o t e i n e m i a may be primary or secondary where the primary type i s e i t h e r f a m i l i a l or s p o r a d i c and the secondary type i s an e x p r e s s i o n o f a l t e r e d metabolism due to some o t h e r r e c o g n i z a b l e d i s e a s e ( F r e d r i c k s o n , Levy and Lees, 1967). Six d i f f e r e n t types of h y p e r l i p o p r o t e i n e m i a have been d e f i n e d by F r e d r i c k s o n est al. (1973) of which type IV i s the most common: Type I - an i n a b i l i t y t o c l e a r c h y l o m i c r o n s . T h i s i s a f a m i l i a l and r a r e d i s o r d e r . 1 Type I l a - c h a r a c t e r i z e d by h y p e r b e t a l i p o p r o t e i n e m i a ( h y p e r c h o l e s t e r o l e m i a ) . The p a t t e r n i s a common one found at a l l ages. Type l i b - a combination of type I l a and type IV. Both i n c r e a s e d b e t a l i p o p r o t e i n s and p r e b e t a l i p o p r o t e i n s are seen. Thus an e l e v a t i o n of serum t r i g l y -c e r i d e s and c h o l e s t e r o l i s e x h i b i t e d . Type I I I - a r e l a t i v e l y uncommon p a t t e r n a s s o c i a t e d w i t h the presence of an abnormal form of b e t a l i p o p r o t e i n . Type IV - h y p e r p r e b e t a l i p o p r o t e i n e m i a ( h y p e r t r i g l y c e r i d e m i a ) . T h i s suggests a m a l f u n c t i o n i n g of carbohydrate metabolism o r c a l o r i c balance. The di s e a s e may be primary or secondary and i s u s u a l l y exacerbated by o b e s i t y . There i s evidence that i t may a l s o be due to e x c e s s i v e a l c o h o l i c i n t a k e or some ot h e r c o n f l i c t between the s u b j e c t and the environment. Type V - c h a r a c t e r i z e d by a mixed h y p e r l i p i d e m i a w i t h both chylomicrons and p r e b e t a l i p o p r o t e i n s e l e v a t e d . T h i s c o n d i t i o n i s o f t e n seen as a secondary d i s o r d e r F r e d r i c k s o n ' s c l a s s i f i c a t i o n of h y p e r l i p o p r o t e i n e m i a (1967) was f i r s t based on e l e c t o p h o r e c t i c t e c h n i q u e s . However, the expenditure of cost and the time a s s o c i a t e d w i t h t h i s method of c l a s s i f i c a t i o n l e d to the development of a simple o f f i c e method (Herriman and C l a r k e , 1971). The serum l e v e l s of c h o l e s t e r o l and t r i g l y c e r i d e t ogether w i t h the p h y s i c a l c h a r a c t e r i s t i c s o f the r e f r i g e r a t e d serum enable the p h y s i c i a n to c l a s s i f y the type o f h y p e r l i p o p r o t e i n e m i a and f o l l o w the e f f e c t s o f therapy. The d i a g n o s i s of h y p e r l i p o p r o t e i n e m i a i s of p r a c t i c a l importance but the fundamental c o n s i d e r a t i o n i s the u n d e r l y i n g f a c t o r s a s s o c i a t e d w i t h the occ u r r e n c e o f the d i s o r d e r . Knowledge of these would p l a y an important r o l e i n d e c r e a s i n g the i n c i d e n c e o f h y p e r l i p o p r o t e i n e m i a . F a c t o r s which have been i m p l i c a t e d i n the e t i o l o g y of h y p e r l i p o p r o t e i n e m i a i n c l u d e n u t r i t i o n a l p r a c t i c e s and r e l a t e d demographic v a r i a b l e s such as body weight, p h y s i c a l a c t i v i t y , smoking and a l c o h o l consumption ( A l b r i n k , 1974). F r e d r i c k s o n , Levy and Lees (1967) i n t h e i r g e n e r a l d e f i n i t i o n of type IV h y p e r l i p o p r o t e i n e m i a suggested t h a t abnormal carbohydrate metabolism, abnormal c a l o r i c b a l a n c e , i n o r d i n a t e emotional s t r e s s , e x c e s s i v e a l c o h o l i c i n t a k e o r genotype may be i n v o l v e d i n t he presence of the d i s o r d e r . Although a l l o f the f a c t o r s c i t e d here have been i n v e s t -i g a t e d and t h e i r r o l e i n the development of h y p e r l i p o p r o t e i n -emia r e p o r t e d i n the l i t e r a t u r e , the importance of the i n t e r r e l a t i o n s h i p among the i n d i v i d u a l f a c t o r s i n most cases has not been s t u d i e d . A l s o the r e l a t i o n s h i p o f these f a c t o r s t o the presence o f h y p e r l i p o p r o t e i n e m i a i n many cases i s very p o o r l y understood. An a s s o c i a t i o n a l study to i n v e s t i g a t e t h i s i s o f utmost importance to a s s i s t i n the d e t e r m i n a t i o n of the cause o r causes of the d i s o r d e r and hence reduce i t s i n c i d e n c e . 4 Statement of the Problem An a s s o c i a t i o n a l study was conducted to i n v e s t i g a t e the r e l a t i o n s h i p of n u t r i t i o n a l p r a c t i c e s and r e l a t e d demo-g r a p h i c v a r i a b l e s t o the presence of h y p e r l i p o p r o t e i n e m i a . The s u b j e c t s i n v e s t i g a t e d were men aged t h i r t y to s i x t y years who were admitted t o S t . P a u l ' s H o s p i t a l f o r c a r d i a c c a t h e t e r i z a t i o n under the care of Dr's. A. Dodek, J . Boone, D. P e r e t z and D. Kavanagh-Gray. P e r s o n a l i n t e r v i e w s were conducted w i t h each s u b j e c t t o o b t a i n i n f o r m a t i o n r e l a t e d t o n u t r i t i o n a l p r a c t i c e s , p h y s i c a l a c t i v i t y , smoking, a l c o h o l consumption, c u r r e n t m e d i c a t i o n s , age and f a m i l y h i s t o r y o f heart d i s e a s e . The t r i c e p s k i n f o l d t h i c k n e s s , h e i g h t , weight and arm circum-f e r e n c e measurements were o b t a i n e d by the r e s e a r c h e r d u r i n g the one i n t e r v i e w . . Serum t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s p l u s f a s t i n g b l o o d glucose l e v e l s were re q u e s t e d o f the h o s p i t a l l a b o r a t o r y at the time o f the i n t e r v i e w , the f a s t i n g samples being o b t a i n e d by the l a b o r a t o r y p e r s o n n e l the f o l l o w i n g morning. The computerized r e s u l t s were a t t a c h e d to the s u b j e c t s medical r e c o r d s from whence they were sec u r e d by the i n t e r v i e w e r . The f o l l o w i n g o b j e c t i v e s were e s t a b l i s h e d f o r i n v e s t i -g a t i n g the problem: 1. To determine the r e l a t i o n s h i p between the amount of sucrose i n the d i e t , as percent o f t o t a l c a rbohydrate, and the presence of h y p e r l i p o p r o t e i n e m i a . 5 2. To determine the r e l a t i o n s h i p between the amount of f a t i n the d i e t , as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 3. To determine the r e l a t i o n s h i p between the P:S r a t i o i n the d i e t and the presence of h y p e r l i p o p r o t e i n e m i a . 4. To determine the r e l a t i o n s h i p beyween the c a l o r i c content of the d i e t and the presence of h y p e r l i p o -p r o t e i n e m i a . 5. To determine the r e l a t i o n s h i p between the amount of s t a r c h i n the d i e t , as percent o f t o t a l c a r b o h y d r a t e , and the presence of h y p e r l i p o p r o t e i n e m i a . 6. To determine the r e l a t i o n s h i p between pond e r a l index and the presence o f h y p e r l i p o p r o t e i n e m i a . 7. To determine the r e l a t i o n s h i p between the amount o f a l c o h o l consumed, as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 8. To determine the r e l a t i o n s h i p between p h y s i c a l a c t i v i t y and the presence o f h y p e r l i p o p r o t e i n e m i a . 9. To determine the r e l a t i o n s h i p between smoking and the presence o f h y p e r l i p o p r o t e i n e m i a . 10. To determine the nature of the i n t e r r e l a t i o n s h i p s between these f a c t o r s and the presence o f h y p e r l i p o -p r o t e i n e m i a . T h i s study was designed t o meet these o b j e c t i v e s , t o develop a p p r o p r i a t e data c o l l e c t i o n instruments f o r the a s s o c i a t i o n a l study and to c o n t r i b u t e to the present know-6 ledge of the f a c t o r s i m p l i c a t e d i n the presence of hyper-l i p o p r o t e i n e m i a . Hypotheses The f o l l o w i n g r e s e a r c h hypotheses were t e s t e d : 1. There w i l l be a p o s i t i v e r e l a t i o n s h i p between the amount of sucrose i n the d i e t , as percent of t o t a l carbohydrate, and the presence of h y p e r l i p o p r o t e i n e m i a . 2. There w i l l be a p o s i t i v e r e l a t i o n s h i p between the amount of f a t i n the d i e t , as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 3. There w i l l be a n e g a t i v e r e l a t i o n s h i p between the P:S r a t i o i n the d i e t and the presence of h y p e r l i p o p r o t e i n -emia . 4. There w i l l be a p o s i t i v e r e l a t i o n s h i p beween the c a l o r i c content of the d i e t and the presence of h y p e r l i p o p r o t e i n -emia . 5. There w i l l be a n e g a t i v e r e l a t i o n s h i p between the amount of s t a r c h i n the d i e t , as percent o f t o t a l carbohydrate, and the presence of h y p e r l i p o p r o t e i n e m i a . 6. There w i l l be a n e g a t i v e r e l a t i o n s h i p between ponderal index and the presence of h y p e r l i p o p r o t e i n e m i a . 7. There w i l l be a p o s i t i v e r e l a t i o n s h i p between the amount of a l c o h o l consumed, as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 8. There w i l l be a n e g a t i v e r e l a t i o n s h i p between p h y s i c a l a c t i v i t y and the presence of h y p e r l i p o p r o t e i n e m i a . 7 9. There w i l l be a p o s i t i v e r e l a t i o n s h i p between smoking and the presence of h y p e r l i p o p r o t e i n e m i a . D e f i n i t i o n of Terms The f o l l o w i n g terms were d e f i n e d f o r the purpose of t h i s study: A s s o c i a t i o n a l study - A study i n which the v a r i a t e i s mani-p u l a b l e but not manipulated (Baker and Schutz,1972). P:S r a t i o - P o l y u n s a t u r a t e d to s a t u r a t e d f a t t y a c i d r a t i o . Percent sucrose - Sucrose as percent t o t a l carbohydrate i n the d i e t . Percent s t a r c h - S t a r c h as percent t o t a l carbohydrate i n the d i e t . Percent f a t - Fat as percent t o t a l c a l o r i e s i n the d i e t . Percent a l c o h o l - A l c o h o l as percent t o t a l c a l o r i e s i n the d i e t . Assumptions The f o l l o w i n g assumptions have been made f o r the purpose o f the study: 1. The d i e t a r y r e c o r d o b t a i n e d from the s u b j e c t was r e p r e -s e n t a t i v e o f h i s normal d i e t a r y i n t a k e . 2. T h i s was the s u b j e c t ' s f i r s t admission f o r c a r d i a c c a t h e t e r i z a t i o n . 8 3. The p h y s i c a l surroundings of the h o s p i t a l ward d i d not b i a s the i n t e r v i e w . 4. The s u b j e c t had no p r i o r p r e s c r i p t i o n f o r the treatment of h y p e r l i p o p r o t e i n e m i a . 5. An a c c u r a t e f a m i l y h i s t o r y o f h eart d i s e a s e was a v a i l -a b l e from the s u b j e c t . 6. Normal p h y s i c a l a c t i v i t y was f a c t u a l l y r e p o r t e d by the s u b j e c t . O r g a n i z a t i o n of the Study The f o l l o w i n g c hapter comprises a review of l i t e r a t u r e p e r t a i n i n g t o the f a c t o r s a s s o c i a t e d w i t h h y p e r l i p o p r o t e i n e m i a i . e . the c r i t e r i o n v a r i a b l e s ( f a s t i n g serum t r i g l y c e r i d e l e v e l and f a s t i n g serum c h o l e s t e r o l l e v e l ) , the v a r i a t e s ( n u t r i t i o n a l p r a c t i c e s , demographic f a c t o r s and anthropometry) and t h e i r r e l a t i o n s h i p to h y p e r l i p o p r o t e i n e m i a . The d e s i g n of the study i n c l u d i n g the p o p u l a t i o n and sample, data c o l l e c -t i o n and data a n a l y s i s i s o u t l i n e d i n Chapter I I I . Chapter IV c o n t a i n s the r e s u l t s of the study w h i l e Chapter V c o n s i s t s of a d i s c u s s i o n o f these r e s u l t s and t h e i r i m p l i c a t i o n s . Appendices c o n t a i n m a t e r i a l s used i n the survey and r e f e r r e d to throughout t h i s r e p o r t . CHAPTER I I REVIEW OF THE LITERATURE D i a g n o s i s and treatment of h y p e r l i p o p r o t e i n e m i a are e s s e n t i a l but an und e r s t a n d i n g o f the f a c t o r s a s s o c i a t e d w i t h the c o n d i t i o n and thus r e d u c t i o n of the i n c i d e n c e of h y p e r l i p o p r o t e i n e m i a would p l a y a s i g n i f i c a n t r o l e i n com-b a t t i n g c a r d i o v a s c u l a r d i s e a s e , one of the major p u b l i c h e a l t h problems e x i s t i n g i n Canada today. H y p e r l i p o p r o t e i n e m i a has been i d e n t i f i e d as one of the main r i s k f a c t o r s of c a r d i o v a s c u l a r d i s e a s e ( P e d i a t r i c s , 1974). The v a r i a t e s observed i n t h i s study ( n u t r i t i o n a l p r a c t i c e s , demographic f a c t o r s and anthropometry) t o g e t h e r w i t h h y p e r l i p o p r o t e i n e m i a and c a r d i o v a s c u l a r d i s e a s e may be c o n s i d e r e d as a t r i a n g l e . e.g. v a r i a t e s h y p e r l i p o p r o t e i n e m i a c a r d i o v a s c u l a r d i s e a s e I t i s of i n t e r e s t t o determine whether the v a r i a t e s are d i r e c t l y a s s o c i a t e d w i t h c a r d i o v a s c u l a r d i s e a s e , indepen-dent of h y p e r l i p o p r o t e i n e m i a , o r whether t h e r e e x i s t s a r e l a t i o n s h i p between the v a r i a t e s and h y p e r l i p o p r o t e i n e m i a . I f a r e l a t i o n s h i p between the v a r i a t e s and h y p e r l i p o p r o t e i n e m i a does e x i s t , the v a r i a t e s then e x e r t t h e i r e f f e c t on c a r d i o -v a s c u l a r d i s e a s e through the presence of h y p e r l i p o p r o t e i n e m i a . 1 0 . T h i s would present an e x c e l l e n t p o i n t at which i n t e r v e n t i o n c o u l d be i n t r o d u c e d . The Framingham Study, a Un i t e d S t a t e s N a t i o n a l Heart I n s t i t u t e e p i d e m i o l o g i c a l i n v e s t i g a t i o n o f c a r d i o v a s c u l a r d i s e a s e , i s perhaps the most th o r o u g h l y conducted and exten-s i v e l y quoted study r e l a t i n g t o heart d i s e a s e . In a d d i t i o n many oth e r s t u d i e s have been p u b l i s h e d and many t h e o r i e s suggested which are important t o c o n s i d e r when i n v e s t i g a t i n g the f a c t o r s l i n k e d w i t h the presence o f h y p e r l i p o p r o t e i n e m i a . T h i s chapter w i l l begin w i t h a review o f the l i t e r a t u r e c o n c e r n i n g the c l a s s i f i c a t i o n o f h y p e r l i p o p r o t e i n e m i a and the importance o f the c r i t e r i o n v a r i a b l e s ( f a s t i n g serum t r i g l y c e r i d e l e v e l and f a s t i n g serum c h o l e s t e r o l l e v e l ) i n e s t a b l i s h i n g the e x i s t e n c e of h y p e r l i p o p r o t e i n e m i a . P u b l i s h e d r e s e a r c h f i n d i n g s and t h e o r i e s p e r t a i n i n g t o the v a r i a t e s ( n u t r i t i o n a l p r a c t i c e s , demographic f a c t o r s and anthropometry) as r e l a t e d t o c a r d i o v a s c u l a r d i s e a s e w i l l t h e n be reviewed. The chapter w i l l conclude w i t h a review of the l i t e r a t u r e c o n c e r n i n g methodology used f o r the a s s e s s -ment of n u t r i t i o n a l p r a c t i c e s and anthropometry. C l a s s i f i c a t i o n o f H y p e r l i p o p r o t e i n e m i a S e v e r a l methods have been suggested f o r the c l a s s i f i -c a t i o n o f h y p e r l i p o p r o t e i n e m i a . One of the f i r s t methods of h y p e r l i p o p r o t e i n e m i a c l a s s i f i c a t i o n was t h a t proposed by F r e d r i c k s o n , Levy and Lees (1967), which was based on e l e c t r o -p h o r e s i s . Although i t was l e s s q u a n t i t a t i v e than u l t r a -c e n t r i f u g a t i o n i t was more convenient and economical. T h i s c l a s s i f i c a t i o n d e f i n e d s i x d i f f e r e n t types o f h y p e r l i p o p r o t e i n e m i a : Type I - an i n a b i l i t y t o c l e a r c h y l o m i c r o n s . Type I l a - c h a r a c t e r i z e d by h y p e r b e t a l i p o p r o t e i n e m i a ( h y p e r c h o l e s t e r o l e m i a ) . Type l i b - shows both i n c r e a s e d b e t a l i p o p r o t e i n s and p r e b e t a l i p o p r o t e i n s . ( T h i s type was added t o the c l a s s i f i c a t i o n i n 1973) . Type I I I _ a s s o c i a t e d w i t h the presence o f an abnormal form of b e t a l i p o p r o t e i n . Type IV - f e a t u r e s h y p e r p r e b e t a l i p o p r o t e i n e m i a ( h y p e r t r i g l y c e r i d e m i a ) . Type V - d e p i c t s a mixed h y p e r l i p i d e m i a w i t h both chylomicrons and p r e b e t a l i p o p r o t e i n s e l e v a t e d . The r e s e a r c h e r s f e l t t h a t o f a l l the methods f o r o b t a i n i n g l i p o p r o t e i n p a t t e r n s a v a i l a b l e at t h a t time o n l y u l t r a c e n t i f u g a t i o n and e l e c t r o p h o r e s i s had the necessary range to c l a s s i f y the d i f f e r e n t types of h y p e r l i p o p r o t e i n e m i a . Ter Welle and W i l l e b r a n d s (1971) adopted a s c r e e n i n g procedure based on the e s t i m a t i o n o f t o t a l l i p i d s , t o t a l c h o l e s t e r o l , and t o t a l t r i g l y c e r i d e s p l u s the l i p o p r o t e i n e l e c t r o p h o r e s i s p a t t e r n on c e l l u l o s e a c e t a t e . Using as t h e i r p r i n c i p a l c r i t e r i o n the t o t a l c h o l e s t e r o l / t o t a l t r i g l y c e r i d e 12 r a t i o they were a b l e t o group t h e i r p a t i e n t s i n t o type I I , I I I o r IV h y p e r l i p o p r o t e i n e m i a . Z o r r i l l a , V a l e n c i a and Serrano (1974) proposed a s c r e e n i n g t e s t f o r h y p e r l i p o p r o t e i n e m i a which was i n t e n d e d t o reduce the time i n v o l v e d i n d i a g n o s i s . T h i s t e s t was based on a p r e v i o u s l y developed method u s i n g a simple m i c r o c a p i l l a r y tube r o u t i n e which was d e v i s e d t o r e v e a l h y p e r l i p o p r o t e i n e m i a and to i n d i c a t e whether the t r i g l y c e r i d e o r c h o l e s t e r o l l e v e l s were i n c r e a s e d . The authors compared"this r o u t i n e w i t h the c o n c e n t r a t i o n of t r i g l y c e r i d e and t o t a l c h o l e s t e r o l and found a s i g n i f i c a n t c o r r e l a t i o n between the l i p i d c o n c e n t r a t i o n s and the h e i g h t o f the c o r r e s p o n d i n g aggregates. They f e l t t h a t the m i c r o c a p i l l a r y tube method c o u l d be u s e f u l f o r s c r e e n i n g purposes although 1.8% f a l s e - n e g a t i v e r e s u l t s were found to be p r e s e n t . The use o f the e s t e r i f i e d f a t t y a c i d index i n the c l a s s i f i c a t i o n and q u a n t i t a t i o n o f h y p e r l i p o p r o t e i n e m i a s has a l s o been suggested ( B i l l i m o r i a , 1971). A f t e r e l e c t r o p h o r e s i s and s t a i n i n g w i t h o i l r e d 0, the bands as observed by r e f l e c t -ance scan n i n g are cut and the c o l o u r e l u t e d by s o l v e n t s . The r e l a t i v e dye uptake i s observed and t h i s t o g e t h e r w i t h the t o t a l e s t e r i f i e d f a t t y a c i d content i s used to determine the e s t e r i f i e d f a t t y a c i d index. As t h i s method of c l a s s i f i c a t i o n i s based on q u a n t i t a -t i o n i t d i f f e r s s l i g h t l y from t h a t of F r e d r i c k s o n , Levy and Lees (1967). The authors f e l t t h a t the use of the e s t i f i e d 13 f a t t y a c i d index f o r the c l a s s i f i c a t i o n o f s e r a i s p a r t i -c u l a r l y u s e f u l t o f o l l o w the p r o g r e s s of each of the l i p o p r o t e i n a b n o r m a l i t i e s a f t e r the a p p r o p r i a t e treatment has been i n s t i t u t e d . The development of a simple o f f i c e method of h y p e r l i p o -p r o t e i n e m i a c l a s s i f i c a t i o n by F r e d r i c k s o n and a s s o c i a t e s has been o u t l i n e d by Hermann and C l a r k e (1971). T h i s method i s based on the d e t e r m i n a t i o n of the serum l e v e l s of both c h o l e s -t e r o l and t r i g l y c e r i d e s t o g e t h e r w i t h the p h y s i c a l c h a r a c t e r -i s t i c s o f the serum f o l l o w i n g o v e r n i g h t r e f r i g e r a t i o n at f o u r degrees c e n t i g r a d e . I t was thought t h a t t h i s method may be p a r t i c u l a r l y u s e f u l f o r the p h y s i c i a n . Hermann and C l a r k e noted: With t h i s chemical and p h y s i c a l data he may ... c l a s s i f y h i s p a t i e n t w i t h h y p e r l i p o p r o t e i n e m i a f a i r l y a c c u r a t e l y without going to the expense of d e t e r m i n i n g the e l e c t r o p h o r e t i c p a t t e r n (p.82). Levy, Bonnel and E r n s t (1971) d i s c u s s i n g the same method s t a t e d : I t i s important to measure both c h o l e s t e r o l and t r i g l y c e r i d e c o n c e n t r a t i o n when e v a l u a t i n g hyper-l i p o p r o t e i n e m i a . Approximately 75% of s u b j e c t s w i t h type IV w i l l be missed i f o n l y a c h o l e s t e r o l d e t e r m i n a t i o n i s performed. S i m i l a r l y , about 75% of type I I s u b j e c t s w i l l be missed i f the c h o l e s t e r o l i s o m i t t e d and o n l y the t r i g l y c e r i d e i s measured. When both l i p i d s are measured more than 95% of i n d i v i d u a l s w i t h h y p e r l i p o p r o t e i n e m i a are d e t e c t e d (p.412). The c o u p l i n g of these simple l i p i d d e t e r m i n a t i o n s w i t h a good medical h i s t o r y and p h y s i c a l examination was suggested by Levy (1973) to be s u f f i c i e n t to determine the 14 l i p o p r o t e i n type p r e s e n t . However he d i d propose that i n c e r t a i n cases, p a r t i c u l a r l y type I I I h y p e r l i p o p r o t e i n e m i a , u l t r a c e n t i f u g a t i o n may be necessary to c o n f i r m the d i a g n o s i s . F i v e r u l e s which Levy f e l t important to f o l l o w a r e : 1. Remember the c o n c e n t r a t i o n of a l l l i p i d s and l i p o -p r o t e i n s i n c r e a s e w i t h age. 2. Chylomicrons normally appear f o r two to t e n hours a f t e r a meal t h e r e f o r e use a f a s t i n g specimen. 3. L i p o p r o t e i n c o n c e n t r a t i o n s are under dynamic m e t a b o l i c c o n t r o l and e a s i l y a f f e c t e d by d i e t , i l l n e s s , drugs, weight g a i n and weight l o s s . Serum l i p i d s change d r a m a t i c a l l y immediately a f t e r a heart a t t a c k . 4. Samples s h o u l d be o b t a i n e d from p a t i e n t s i n a steady s t a t e and on a r e g u l a r d i e t . 5. When h y p e r l i p o p r o t e i n e m i a i s secondary to another d i s o r d e r , treatment of that d i s o r d e r w i l l u s u a l l y modify the h y p e r l i p o p r o t e i n e m i a e f f e c t i v e l y . The d i s c o n t i n u a t i o n of l i p o p r o t e i n e l e c t r o p h o r e s i s as a r o u t i n e procedure was porposed by Iammarino (1975). The author's statement was based on the f o l l o w i n g o bserva-t i o n s : 1. There i s s i g n i f i c a n t o v e r l a p between the i n t e r -p r e t a t i o n g i v e n to data generated by l i p i d a n a l y s i s and the i n t e r p r e t a t i o n of l i p o p r o t e i n e l e c t r o p h o r e s i s . 2. Types I, I I I and V are r a r e l y seen. 15 3. There are problems a s s o c i a t e d w i t h the study of l i p i d s i n h o s p i t a l i z e d p a t i e n t s . 4. Newer concepts of l i p o p r o t e i n metabolism have changed our views on the i n t e r r e l a t i o n s h i p s of F r e d r i c k s o n t y p e s . T h e r e f o r e lammarino suggests that plasma l i p i d s may be e v a l u a t e d from the plasma t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s w i t h e l e c t r o p h o r e s i s being r e s e r v e d f o r those specimens wit h t r i g l y c e r i d e c o n c e n t r a t i o n s g r e a t e r than 350mg/dl. From t h i s b r i e f review of the l i t e r a t u r e i t would appear t h a t a p r a c t i c a l , r a p i d and i n e x p e n s i v e approach to the d i a g -n o s i s and c l a s s i f i c a t i o n of h y p e r l i p o p r o t e i n e m i a i s a necessary requirement which at the moment seems to be met by determina-t i o n o f the f a s t i n g l e v e l s of serum t r i g l y c e r i d e s and c h o l e s -t e r o l . C r i t e r i o n V a r i a b l e s F a s t i n g Serum T r i g l y c e r i d e and C h o l e s t e r o l L e v e l s The importance of the f a s t i n g serum t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s i n e s t a b l i s h i n g the presence of hyper-l i p o p r o t e i n e m i a has been d i s c u s s e d i n the p r e v i o u s s e c t i o n . Levy, B o n n e l l and E r n s t (1971) suggest t h a t "with the p e r s o n a l and f a m i l y h i s t o r y , p h y s i c a l f i n d i n g s , c h o l e s t e r o l and t r i g l y c e r i d e measurements, i t i s o f t e n p o s s i b l e to e s t a b l i s h the type of h y p e r l i p o p r o t e i n e m i a . " T h e r e f o r e i t would appear that the f a s t i n g serum l e v e l s of t r i g l y c e r i d e s 16 and c h o l e s t e r o l are the two important c r i t e r i o n v a r i a b l e s which s h o u l d be employed when s u r v e y i n g the r i s k f a c t o r s i n v o l v e d i n the presence of h y p e r l i p o p r o t e i n e m i a . V a r i a t e s N u t r i t i o n a l P r a c t i c e s D i e t a r y carbohydrate S e v e r a l s t u d i e s have been conducted t o i n v e s t i g a t e the e f f e c t o f s p e c i f i c types o f d i e t a r y carbohydrate on the l i p i d l e v e l s o f h y p e r l i p o p r o t e i n e m i a p a t i e n t s . Kaufmann and K a p i t u l n i k (1972) i n t h e i r o b s e r v a t i o n s among p a t i e n t s w i t h carbohydrate-induced h y p e r l i p o p r o t e i n e m i a found t h a t the i s o c a l o r i c s u b s t i t u t i o n o f sucrose f o r s t a r c h u s u a l l y caused; a f u r t h e r i n c r e a s e i n serum t r i g l y c e r i d e and t o t a l c h o l e s t e r o l l e v e l s . They a l s o found t h a t the f e e d i n g of f r u c t o s e , but not of g l u c o s e , l e d to an i n c r e a s e o f s e r u m l i p i d s i n normal s u b j e c t s s i m i l a r t o t h a t f o l l o w i n g s ucrose f e e d i n g . Comparable f i n d i n g s were observed by N i k k i l a and Kekki (1972). The e f f e c t o f o r a l a d m i n i s t r a t i o n o f sucrose on the tu r n o v e r r a t e of plasma f r e e f a t t y a c i d s and on the e s t e r -i f i c a t i o n r a t e of plasma f r e e f a t t y a c i d s t o plasma t r i g l y c e r i d e s i n normal s u b j e c t s , p a t i e n t s w i t h primary endogenous h y p e r t r i g l y c e r i d e m i a (type IV h y p e r l i p o p r o t e i n e m i a ) , and p a t i e n t s w i t h w e l l - c o n t r o l l e d d i a b e t e s was noted by 17 Bolzana et a l . (1972). They suggested that the plasma-free f a t t y a c i d s are the primary source of endogenous plasma-t r i g l y c e r i d e s but were i n t e r e s t e d to observe i f the h i g h c o n c e n t r a t i o n of plasma t r i g l y c e r i d e s i n type IV h y p e r l i p o -p r o t e i n e m i c p a t i e n t s was due to i n c r e a s e d s y n t h e s i s of t r i g l y c e r i d e s or to i n s u f f i c e n t removal of t r i g l y c e r i d e s from "plasma. The study r e v e a l e d t h a t the a d m i n i s t r a t i o n of sucrose caused a s i g n i f i c a n t decrease i n the c o n c e n t r a t i o n and t u r n o v e r r a t e of f r e e f a t t y a c i d s i n the plasma but a s i g n i f i c a n t i n c r e a s e i n the f r a c t i o n of plasma-free f a t t y a c i d s which was e s t e r i f i e d t o p l a s m a - t r i g l y c e r i d e s per u n i t time i n a l l three groups of s u b j e c t s . During sucrose l o a d i n g the t o t a l e s t e r i f i c a t i o n r a t e o f plasma-free f a t t y a c i d s to plasma t r i g l y c e r i d e s was s i g n i f i c a n t l y h i g h e r i n h y p e r l i p o p r o t e i n -emics than i n the normals. T h i s , the authors suggested, was a r e s u l t o f the weaker f r e e f a t t y a c i d l o w e r i n g e f f e c t of s u c r o s e i n these p a t i e n t s as compared w i t h the normal s u b j e c t s . It was concluded from the study t h a t the h i g h plasma t r i g l y c e r i d e c o n c e n t r a t i o n i n the h y p e r l i p o p r o t e i n e m i c p a t i e n t s was due to i n s u f f i c i e n t removal of t r i g l y c e r i d e s from plasma both i n the f a s t i n g s t a t e and d u r i n g acute sucrose l o a d i n g r a t h e r than t o i n c r e a s e d s y n t h e s i s . H u l l e y et a l . (1972) t e s t e d the e f f e c t of an i s o - c a l o r i c d i e t on non-obese men w i t h type IV h y p e r l i p o p r o t e i n e m i a . The s u b j e c t s were maintained on the Standard American Heart A s s o c i a t i o n d i e t f o r s i x months f o l l o w e d by a second s i x -month treatment of a low carbohydrate m o d i f i c a t i o n of the s t a n d a r d d i e t . The r e s e a r c h e r s concluded from the study t h a t : 1. Low-carbohydrate d i e t s lower serum t r i g l y c e r i d e c o n c e n t r a t i o n by r e d u c i n g the r a t e of p r e b e t a l i p o -p r o t e i n p r o d u c t i o n . 2. D i e t s of extremely h i g h carbohydrate content i n c r e a s e serum t r i g l y c e r i d e c o n c e n t r a t i o n by i n c r e a s i n g the r a t e of p r e b e t a l i p o p r o t e i n p r o d u c t i o n . 3. The s l i g h t l y (2%) i n c r e a s e d carbohydrate content of the American Heart A s s o c i a t i o n d i e t does not change p r e b e t a l i p o p r o t e i n l e v e l s . That the decreased c l e a r a n c e o f t r i g l y c e r i d e s from plasma may c o n t r i b u t e t o c a r b o h y d r a t e - i n d u c e d h y p e r l i p o -p r o t e i n e m i a i n normal humans i s a l s o suggested by Mancini et a l . (1973). They s t u d i e d normal s u b j e c t s consuming a h i g h carbohydrate d i e t (7 - 7.5 gms. carbohydrate/kg.body weight/day). A c o m p o s i t i o n a l change was observed i n the very low d e n s i t y l i p o p r o t e i n s which i s not e a s i l y e x p l a i n e d by i n c r e a s e d r a t e s of t r i g l y c e r i d e uptake alone i . e . a r i s e i n t r i g l y c e r i d e / p r o t e i n r a t i o and t r i g l y c e r i d e / c h o l e s t e r o l r a t i o which marked a t r e n d away from the normal c o m p o s i t i o n o f very low d e n s i t y l i p o p r o t e i n s towards that of c h y l o m i c r a . A l s o the i n t r a v e n o u s f a t t o l e r a n c e t e s t showed a decrease i n the f r a c t i o n a l r a t e of disappearance o f i n j e c t e d t r i -g l y c e r i d e s from plasma d u r i n g carbohydrate i n d u c t i o n . T h e r e f o r e the authors proposed that the e l e v a t i o n of plasma t r i g l y c e r i d e l e v e l s d u r i n g h i g h carbohydrate i n t a k e s may be a t t r i b u t a b l e both to decreased removal and i n c r e a s e d s e c r e t i o n of t r i g l y c e r i d e s . DenBesten et a l . (1973) compared the e f f e c t s of high carbohydrate f e e d i n g on serum l i p i d s and the s t e r o l balance when i d e n t i c a l formulas were g i v e n e n t r a v e n o u s l y and i n t r a -g a s t r i c a l y to the same s u b j e c t i n s e q u e n t i a l f a s h i o n . The o r a l a d m i n i s t r a t i o n of the high carbohydrate n u t r i e n t mixture produced a h y p e r t r i g l y c e r i d e m i a which was not seen when the mucosa was by-passed u s i n g i n t r a v e n o u s a d m i n i s t r a t i o n . Although the mechanism has yet to be c l e a r l y d e l i n e a t e d the authors suggest t h a t the i n t e s t i n a l mucosa may p l a y an important r o l e i n carbohydrate-induced h y p e r l i p o p r o t e i n e m i a . N a i s m i t h , Stock and Yudkin (1974) s t u d i e d 23 s t u d e n t s . The s u b j e c t s consumed an i s o - c a l o r i c d i e t f o r 14 days i n which 200 gms. of sucrose were r e p l a c e d by a s i m i l a r amount of s t a r c h . The t r i g l y c e r i d e , c h o l e s t e r o l and p h o s p h o l i p i d plasma c o n c e n t r a t i o n i n c r e a s e d but r e t u r n e d to normal w i t h i n 14 days on a normal d i e t . The d i e t s were then i n c r e a s e d by 1800 c a l o r i e s . In some s u b j e c t s the sucrose was reduced to 32 gms./day wh i l e i n o t h e r s i t was i n c r e a s e d to 219 gms./day. The r e s u l t s showed t h a t the i n c r e a s e d c a l o r i e but low sucrose d i e t had no s i g n i f i c a n t e f f e c t on the t r i g l y c e r i d e l e v e l w h i l e the i n c r e a s e d c a l o r i e but h i g h - s u c r o s e d i e t was a s s o c i a t e d w i t h an i n c r e a s e d plasma t r i g l y c e r i d e c o n c e n t r a t i o n . 20 The r e s e a r c h e r s concluded from t h e i r r e s u l t s t h a t the e l e v a t i o n i n plasma l i p i d s observed when h i g h sucrose d i e t s were consumed cannot be a s c r i b e d to an i n c r e a s e i n energy i n t a k e but r a t h e r i s due to the h y p e r l i p e m i c p r o p e r t y of the sucrose i t s e l f . It i s now g e n e r a l l y r e c o g n i s e d that a h i g h carbohydrate i n t a k e tends to e l e v a t e the plasma t r i g l y c e r i d e l e v e l , h i g h sucrose and f r u c t o s e i n t a k e s having a more h y p e r t r i g l y c e r i -demia e f f e c t than a h i g h s t a r c h i n t a k e . Most of the s t u d i e s conducted to observe the e f f e c t o f d i f f e r e n t types of carbohydrate on the serum l i p i d l e v e l s of normal and h y p e r l i p i d e m i c s u b j e c t s have noted the e f f e c t due to carbohydrate l o a d i n g r a t h e r than the e f f e c t of normal d i e t a r y p r a c t i c e s . A l s o the e f f e c t of c a r b o h y d r a t e - f e e d i n g on the h y p e r l i p i d e m i c p a t i e n t w i l l depend on the type of h y p e r l i p o p r o t e i n e m i a present i . e . h y p e r l i p o p r o t e i n e m i a due t o exogenous l i p i d s o r h y p e r l i p o p r o t e i n e m i a due to i n c r e a s e d l e v e l s of endogenous l i p i d s . The r o l e which the q u a l i t y and/or q u a n t i t y of carbohydrate p l a y s i n the development of h y p e r l i p o p r o t e i n e m i a would be of c o n s i d e r a b l e i n t e r e s t i n d e c r e a s i n g the i n c i d e n c e of c a r d i o v a s c u l a r d i s e a s e . D i e t a r y l i p i d s The P:S r a t i o present i n the d i e t has a l s o been c i t e d as an important f a c t o r i n the presence o f h y p e r l i p o p r o t e i n e m i a . L i t t l e et a l . (1970) i n t h e i r s t u d i e s w i t h h y p e r l i p o p r o t e i n e m i c 21 p a t i e n t s found that sucrose was h y p e r l i p i d e m i c as compared w i t h s t a r c h o n l y i n d i e t s c o n t a i n i n g predominantly s a t u r a t e d f a t t y a c i d s and l a r g e amounts of c h o l e s t e r o l . I f the d i e t s were high i n p o l y u n s a t u r a t e d f a t t y a c i d s w i t h p r a c t i c a l l y no c h o l e s t e r o l or had mixed s a t u r a t e d and u n s a t u r a t e d f a t s and s m a l l amounts of c h o l e s t e r o l , the sucrose had no d e f i n i t e h y p e r l i p i d e m i c e f f e c t . These r e s u l t s show the importance of s t u d y i n g d i e t a r y p r a c t i c e s as a whole r a t h e r than o b s e r v i n g the e f f e c t of i n d i v i d u a l n u t r i e n t s . The a d d i t i o n of p o l y u n s a t u r a t e d f a t t y a c i d s to the d i e t augments the c h o l e s t e r o l - l o w e r i n g e f f e c t ( A l b r i n k , 1974). Levy, B o n n e l l and E r n s t (1971) recommended the use of p o l y -u n s a t u r a t e d f a t s i n the d i e t a r y management of a l l types of h y p e r l i p o p r o t e i n e m i a , except type I, i n p r e f e r e n c e to s a t u r -ated f a t s . I t has a l s o been s t a t e d by H u l l e y et a l . (1972) t h a t : D i e t s which c o n t a i n f a t of hi g h P/S r a t i o and r e l a t i v e l y l i t t l e c h o l e s t e r o l (e.g. the s t a n d a r d American Heart Ass. d i e t ) lower s e r u m - c h o l e s t e r o l c o n c e n t r a t i o n by d e c r e a s i n g b e t a l i p o p r o t e i n l e v e l s (p.554). From t h e i r experiments on the e f f e c t of d i e t on serum c h o l e s t e r o l l e v e l s i n humans, Anderson, Grande and Keys (1973) found that d i e t a r y f a t s i n f l u e n c e serum c h o l e s t e r o l depending on the p r o p o r t i o n of s a t u r a t e d and p o l y u n s a t u r a t e d f a t t y a c i d s . They observed t h a t s a t u r a t e d f a t t y a c i d g l y c e r i d e s have a c h o l e s t e r o l - r a i s i n g e f f e c t which i s a p p r o x i -mately twice the c h o l e s t e r o l - l o w e r i n g e f f e c t of p o l y u n s a t u r a t e d f a t t y a c i d g l y c e r i d e s . The amount of f a t i n the d i e t as percent of t o t a l c a l o r i e s i s a suggested f a c t o r i n the presence of hyper-l i p o p r o t e i n e m i a due to the p a r a l l e l i n c r e a s e i n exogenous f a t and the c a l o r i c i n t a k e . An excess of d i e t a r y f a t i s c o n s i d e r e d a p o s s i b l e r i s k f a c t o r f o r i s c h e m i c heart d i s e a s e by the A d v i s o r y Panel of the B r i t i s h Committee on M e d i c a l Aspects of Food P o l i c y ( N u t r i t i o n ) on D i e t i n r e l a t i o n t o C a r d i o v a s c u l a r and C e r e b r o v a s c u l a r d i s e a s e (1975). They s t a t e : The r e s u l t s of comparative s t u d i e s of the p o p u l a t i o n of v a r i o u s c o u n t r i e s agree i n g e n e r a l that the death r a t e from i s c h e m i c heart d i s e a s e c o r r e l a t e s p o s i t i v e l y w i t h the average p r o p o r t i o n of the food energy which i s d e r i v e d from f a t , and the c o r r e l a t i o n i s b e t t e r w i t h the p r o p o r t i o n of food energy d e r i v e d from s a t u r -a t e d f a t t y a c i d s than w i t h the p r o p o r t i o n d e r i v e d from the t o t a l amount of f a t i n the food (p.25). Sherwin (1974) suggested that the fundamental c h a r a c t e r -i s t i c o f an a n t i a t h e r o g e n i c d i e t i s one i n which the f a t content i s 30% of the t o t a l c a l o r i e s w i t h the l i m i t a t i o n of s a t u r a t e d f a t and c h o l e s t e r o l . A l s o the r e s t r i c t i o n of simple sugars but a d d i t i o n of some p o l y u n s a t u r a t e d f a t was a d v i s e d . S i m i l a r l y Kannel (1971) proposed that the t o t a l f a t content of an a c c e p t a b l e d i e t s h o u l d be below 30% of the c a l o r i e s , the P:S r a t i o 2:1 and the c h o l e s t e r o l i n t a k e under 250 mg. d a i l y . I t s h o u l d be noted that t o g e t h e r w i t h these s u g g e s t i o n s Kannel a l s o made recommendations r e g a r d i n g t o t a l c a l o r i e s ( s u f f i c i e n t t o m a i n t a i n l e a n body w e i g h t ) , simple sugars ( l i m i t e d i n t a k e ) and t a b l e s a l t ( l e s s than f o u r grams 23 per day) emphasizing a g a i n the importance of r e g a r d i n g the d i e t as a whole r a t h e r than c o n c e n t r a t i n g on one p a r t i c u l a r component. T o t a l c a l o r i e s A r e l a t i o n s h i p between o b e s i t y and plasma l i p i d s has been demonstrated by s e v e r a l r e s e a r c h e r s . Okefsky, Reaven and Farquakar (1974 a) observed marked decreases, a f t e r weight r e d u c t i o n , i n f a s t i n g plasma t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s , w i t h a d i r e c t r e l a t i o n s h i p between the magnitude of the f a l l i n the plasma l i p i d v a l u e s and the h e i g h t of the i n i t i a l plasma t r i g l y c e r i d e l e v e l . L i s c k et a l . (1974) i n t h e i r i n v e s t i g a t i o n of p a t i e n t s w i t h h y p e r l i p o p r o t e i n e m i a found that weight r e d u c t i o n c o u l d be c o r r e l a t e d w i t h a decrease i n the plasma t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s i n p a t i e n t s w i t h type l i b and type I I I h y p e r l i p o p r o t e i n e m i a . However they d i d f i n d t h a t no e f f e c t of weight r e d u c t i o n c o u l d be shown i n some of the type IV h y p e r l i p o p r o t e i n e m i c s u b j e c t s and a l l of the type V s u b j e c t s . These r e s u l t s d i d not agree w i t h those of O l e f s k y , Reaven and Farquaker (1974 a) who observed a marked decrease i n f a s t i n g plasma t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s w i t h weight r e d u c t i o n i n type l i b , type I I I and type IV h y p e r l i p o p r o t e i n -emic p a t i e n t s . Nonetheless i t does appear that although o b e s i t y may not be the s o l e o r even major cause of the abnorm-a l i t y i n the f i r s t p l a c e , weight r e d u c t i o n i s an important f a c t o r to c o n s i d e r i n the treatment of the endogenous hyper-24 . t r i g l y c e r i d e m i a (type l i b , I I I and IV h y p e r l i p o p r o t e i n e m i a ) . The importance of o b s e r v i n g the e f f e c t on the plasma l i p i d l e v e l s c r e a t e d by s e v e r a l f a c t o r s i n the d i e t i s i l l u s t r a t e d by H a l l et a l . (1972). They used a d i e t "low i n s a t u r a t e d f a t and c h o l e s t e r o l , moderate i n p o l y u n s a t u r a t e d f a t , moderate i n t o t a l f a t and carbohydrate and c a l o r i e -c o n t r o l l e d t o lower weight." Among the 114 men, 98 of whom were obese and 50 h y p e r l i p o p r o t e i n e m i c , r e d u c t i o n s i n serum t r i g l y c e r i d e s of 17.3%, serum c h o l e s t e r o l of 12.1% and weight of 5.3% were seen. Serum c h o l e s t e r o l , blood p r e s s u r e , b l o o d glucose and u r i c a c i d v a l u e s have a l l been suggested as r i s k f a c t o r s o f c a r d i o v a s c u l a r d i s e a s e . Ashley and Kannel (1974) s t u d i e d the data from the Framingham Study to examine the e f f e c t of weight r e d u c t i o n on a l l o f these f a c t o r s . They observed t h a t a change i n r e l a t i v e weight had the g r e a t e s t impact on c h o l e s t e r o l and i n descending o r d e r , on s y s t o l i c b l o o d p r e s s u r e , u r i c a c i d and b l o o d g l u c o s e . The authors suggested t h a t weight g a i n i s accompanied by a t h e r o g e n i c a l t e r a t i o n s i n b l o o d l i p i d s and r e g a r d l e s s of whether the n u t r i e n t composi-t i o n o f the c a l o r i e s or the p o s i t i v e energy balance per se i s r e s p o n s i b l e f o r t h i s change, o r d i n a r y o b e s i t y encountered i n the g e n e r a l p o p u l a t i o n i s a s s o c i a t e d w i t h excess presence of h y p e r l i p o p r o t e i n e m i a . The i n f l u e n c e of o b e s i t y on the r e l a t i o n s h i p between i n s u l i n and t r i g l y c e r i d e l e v e l s i n endogenous h y p e r t r i g l y c e r i -25 demia was examined by Bagdade, Bierman and Por t e (1971). It was proposed that t i s s u e i n s u l i n r e s i s t a n c e i n obese s u b j e c t s may p l a y an important r o l e i n unmasking u n d e r l y i n g a b n o r m a l i t i e s i n t r i g l y c e r i d e t r a n s p o r t through the secondary a l t e r a t i o n s produced i n i n s u l i n s e c r e t i o n . The authors con-c l u d e d t h a t h i g h i n s u l i n l e v e l s i n s u b j e c t s who demonstrate many of the c h a r a c t e r i s t i c s o f endogenous h y p e r l i p o p r o t e i n e m i a appear to be due to o b e s i t y , when i t c o e x i s t s . T h i s i n t u r n may c o n t r i b u t e to but not n e c e s s a r i l y cause the d i s t u r b a n c e t o t r i g l y c e r i d e homeostases. It i s d i f f i c u l t to assess i f the e f f e c t of o b e s i t y per se o r the e f f e c t of o b e s i t y on o t h e r r i s k f a c t o r s such as h y p e r t e n s i o n , impaired glucose t o l e r a n c e and h y p e r l i p e m i a i n c r e a s e s the occurrence of c a r d i o v a s c u l a r d i s e a s e . Regard-l e s s , the maintenance o f i d e a l body weight would appear a prudent recommendation to decrease the i n c i d e n c e of h y p e r l i p o -p r o t e i n e m i a . A l c o h o l i n t a k e Although l i t t l e r e s e a r c h appears to have been conducted to i n v e s t i g a t e the r e l a t i o n s h i p of a l c o h o l i n t a k e t o l e v e l s of plasma t r i g l y c e r i d e and c h o l e s t e r o l , i t has been suggested that a h i g h i n t a k e of a l c o h o l i s a s s o c i a t e d w i t h h y p e r l i p o -p r o t e i n e m i a . A l b r i n k (1974) i n d i c a t e d t h a t : . . . a l c o h o l may r a i s e t r i g l y c e r i d e l e v e l s and sh o u l d be omitted or c u r t a i l e d i n p a t i e n t s w i t h h y p e r t r i g l y c e r i d e m i a (p.91). 26 It has a l s o been proposed by F r e d r i c k s o n et a l . (1967) that h y p e r l i p o p r o t e i n e m i a may be a c q u i r e d from a p a t t e r n of excess a l c o h o l i n t a k e . L i t t l e et al.(1970) s t a t e d t h a t h y p e r l i p i d e m i c e f f e c t of a l c o h o l may depend on the propor-t i o n s o f d i e t a r y s a t u r a t e d and p o l y u n s a t u r a t e d f a t . The p r e c u r s o r s of plasma t r i g l y c e r i d e f a t t y a c i d s i n humans were s t u d i e d by B a r t e r , N e s t e l and C a r r o l l (1971). They concluded from t h e i r o b s e r v a t i o n s t h a t the s t o r e d h e p a t i c f a t t y a c i d s appeared to be a source of plasma t r i -g l y c e r i d e s i n s u b j e c t s w i t h a l c o h o l i c f a t t y l i v e r whereas i n h e a l t h y s u b j e c t s the plasma t r i g l y c e r i d e s newly formed i n the p o s t - a b s o r p t i v e s t a t e are d e r i v e d predominantly from plasma f r e e f a t t y a c i d s . Gibson and Grahame (1974) i n v e s t i g a t e d the q u e s t i o n of whether the h y p e r l i p o p r o t e i n e m i a seen i n s u b j e c t s s u f f e r i n g from gout i s r e l a t e d to t h e i r gout per se or whether i t can be e x p l a i n e d on the b a s i s of the o b e s i t y or d r i n k i n g h a b i t s that many of them d i s p l a y . F a s t i n g t r i g l y c e r i d e and c h o l e s -t e r o l v a l u e s i n f o r t y s u b j e c t s demonstrating gout were compared w i t h those observed i n an equal number of abstemious c o n t r o l s matched f o r age, sex and p o n d e r a l index. The authors observed that the s u b j e c t s w i t h gout who were heavy d r i n k e r s had s i g n i f i -c a n t l y h i g h e r t r i g l y c e r i d e l e v e l s than the n o n - d r i n k i n g s u b j e c t s w i t h and without gout. However the i n c r e a s e i n serum t r i g l y c e r i d e v a l u e s a s s o c i a t e d w i t h o b e s i t y was s i m i l a r i n both groups. 27 B a l a r t et a l . (1974) found no s i g n i f i c a n t c o r r e l a t i o n between serum c h o l e s t e r o l and the d a i l y i n t a k e of a l c o h o l , c h o l e s t e r o l or carbohydrate when they i n v e s t i g a t e d 104 m e d i c a l s t u d e n t s . No mention was made of the c o r r e l a t i o n between the above f a c t o r s and the serum t r i g l y c e r i d e l e v e l s observed i n the study. S e v e r a l r i s k f a c t o r s a s s o c i a t e d w i t h i s c h e m i c heart d i s e a s e were observed i n an a p p a r e n t l y h e a l t h y London popu-l a t i o n by Lewis et a l . (1974). They noted a p o s i t i v e c o r r e l a t i o n between very low d e n s i t y l i p o p r o t e i n - t r i g l y c e r i d e c o n c e n t r a t i o n and a l c o h o l i n t a k e . T h i s c o r r e l a t i o n remained s i g n i f i c a n t when the weight-height index was h e l d constant thus a l l o w i n g f o r any r e l a t i o n s h i p between o b e s i t y and a l c o h o l consumption. Demographic F a c t o r s Smoking From the data o b t a i n e d i n the Framingham study, Kannel et a l . (1964) noted t h a t i f a s u b j e c t has a h i s t o r y of e x c e s s i v e c i g a r e t t e smoking the r i s k of v a r i o u s m a n i f e s t a t i o n s of coronary heart d i s e a s e i s compounded. In 1971 Kannel s t a t e d t h a t : D i s c o u r a g i n g the use of c i g a r e t t e s must be a prominent f e a t u r e of any comprehensive programme of l i f e - s t y l e c o n t r o l designed to prevent a t h e r o s c l e r o t i c d i s e a s e . . . It makes a unique c o n t r i b u t i o n to coronary d i s e a s e independent of o t h e r r i s k f a c t o r s ( p . 6 ) . 28 Sherwin (1974) noted that one of the r i s k f a c t o r s i n i n d i v i d u a l s who subsequently develop coronary heart d i s e a s e i s smoking. The r i s k i n c r e a s e s w i t h the number of c i g a r e t t e s smoked each day and i n c r e a s e s e x p o n e n t i a l l y when two or more packs are smoked every day. He a l s o observed, from data o b t a i n e d i n U n i t e d S t a t e s s u r v e y s , that a low r i s k of coronary heart d i s e a s e e x i s t e d among ex-smokers thereby emphasizing the f a c t that " i t i s never too l a t e to q u i t . " The r e p o r t o f the A d v i s o r y Panel of the B r i t i s h Committee on M e d i c a l Aspects of Food P o l i c y ( N u t r i t i o n ) on D i e t i n r e l a -t i o n to C a r d i o v a s c u l a r and C e r e b r o v a s c u l a r d i s e a s e (1975) i n c l u d e s the statement t h a t : The a s s e r t i o n ... cannot be made that e x c e s s i v e smoking i s an e s s e n t i a l cause of coronary d i s e a s e : n e v e r t h e l e s s i t i s a r i s k f a c t o r i n the sense that among smokers the p r o b a b i l i t y o f d e v e l o p i n g the dis e a s e i s g r e a t e r than i t i s among non-smokers (p.18). It has been noted ( L i t t l e 1974) that those who s u f f e r a heart a t t a c k tend t o have one o r more s o - c a l l e d r i s k f a c t o r s which i n c l u d e : 1. E l e v a t i o n of plasma l i p i d s as measured by c h o l e s t e r o l and t r i g l y c e r i d e s and o f t e n r e f e r r e d to as h y p e r l i p o -p r o t e i n e m i a . 2. High bl o o d p r e s s u r e . 3. C i g a r e t t e smoking. 4. D i a b e t e s . 5. O b e s i t y . 29 The a c t u a l way i n which smoking i s r e l a t e d to c a r d i o -v a s c u l a r d i s e a s e i s of i n t e r e s t when i n v e s t i g a t i n g the v a r i a t e s a s s o c i a t e d with the presence of h y p e r l i p o p r o t e i n e m i a . Does smoking l e a d to h y p e r l i p o p r o t e i n e m i a and hence c a r d i o v a s c u l a r d i s e a s e ? Astrup and K j e l d s e n (1973) i n v e s t i g a t e d the patho-p h y s i o l o g i c mechanisms i n v o l v e d i n the development of a t h e r o -s c l e r o s i s i n smokers. They exposed c h o l e s t e r o l - f e d r a b b i t s to carbon monoxide (170 p.p.m. f o r 7 weeks f o l l o w e d by 340 p.p.m. f o r 2 weeks). The c h o l e s t r o l content of the a o r t a of the c h o l e s t e r o l - f e d r a b b i t s was 2.5 times h i g h e r than i n the c o n t r o l r a b b i t s who had a l s o been f e d c h o l e s t e r o l but had not been exposed to carbon monoxide. The authors a l s o r e p o r t e d t h a t many i n v e s t i g a t o r s have found approximately 10-15 mg./lOO mis. h i g h e r c h o l e s t e r o l l e v e l s i n smokers i n comparison w i t h non-smokers. T h e r e f o r e i t would appear that the mode of a c t i o n of smoking as r e l a t e d to the presence of c a r d i o v a s c u l a r d i s e a s e i s as yet unknown. One o f the o b j e c t i v e s of t h i s study i s to determine the r e l a t i o n s h i p of smoking (a v a r i a t e ) to the c r i t e r i o n v a r i a b l e s (serum c h o l e s t e r o l and t r i g l y c e r i d e l e v e l s ) . \ P h y s i c a l e x e r c i s e Kannel (1971), r e p o r t i n g on the Framingham study, s t a t e d : 30 ... assessment o f the r i s k of d i s e a s e , u s i n g v a r i o u s i n d i c e s of h a b i t u a l energy e x p e n d i t u r e , has i n d i c a t e d that sedentary men are more s u s c e p t i b l e to coronary a t t a c k s than are p h y s i c a l l y a c t i v e men. The l e a s t a c t i v e men had about three times the r i s k of those most a c t i v e p h y s i c a l l y (p.6). The e f f e c t s of a six-month programme of endurance e x e r c i s e on the serum l i p i d s of middle-aged men was s t u d i e d by H o l l o s z y et a l . (1964). They attempted to determine whether or not r e g u l a r e x e r c i s e p r o t e c t s a g a i n s t the develop-ment of coronary heart d i s e a s e through the a l t e r a t i o n of l i p i d metabolism. Serum c h o l e s t e r o l , p h o s p h o l i p i d and t r i g l y c e r i d e l e v e l s were observed d u r i n g the six-month p e r i o d . From the r e s u l t s of the study the authors concluded that r e g u l a r exer-c i s e w i l l s i g n i f i c a n t l y lower serum t r i g l y c e r i d e l e v e l s but w i l l have no e f f e c t on the serum c h o l e s t e r o l or p h o s p h o l i p i d l e v e l s . Mannet a l . (1955) had e a r l i e r proposed t h a t a p o s i t i v e c a l o r i c balance over a l o n g p e r i o d e l e v a t e s the serum l i p i d l e v e l s and c o n t r i b u t e s t o a t h e r o g e n e s i s . The e f f e c t of i n c r e a s e d c a l o r i c i n t a k e both w i t h and without i n c r e a s e d energy ex p e n d i t u r e was observed i n f o u r young male s u b j e c t s . So l o n g as the excess energy was d i s s i p a t e d as e x e r c i s e no i n c r e a s e was observed i n the l e v e l of serum l i p i d s . B l o o d l i p i d and glucose l e v e l s d u r i n g a ten-day p e r i o d o f zero c a l o r i c i n t a k e and i n c r e a s e d e x e r c i s e were observed i n twelve men by C a r l s o n and Froberg (1967). They suggested that although, i n d e p e n d e n t l y , e x e r c i s e o r f a s t i n g do not 31 appear to decrease the plasma c h o l e s t e r o l c o n c e n t r a t i o n , when weight l o s s o c c u r s i n c o n j u n c t i o n w i t h p h y s i c a l t r a i n -i n g a r e d u c t i o n i n the plasma c h o l e s t e r o l l e v e l may o c c u r . Plasma t r i g l y c e r i d e and p h o s p h o l i p i d l e v e l s dropped markedly d u r i n g the study w h i l e the mean bloo d glucose l e v e l decreased d u r i n g the f i r s t 6 days and then i n c r e a s e d 12-5 mg./lOO ml. above the i n i t i a l value - an e f f e c t which i s n o r m a l l y seen d u r i n g f a s t i n g . I t has been suggested that p h y s i c a l e x e r c i s e may i n c r e a s e the c l e a r i n g of v i s i b l e l i p e m i a f o l l o w i n g a f a t t y meal (Cohen and Goldberg, 1960). In t h e i r s t u d i e s w i t h twenty-two young men and women the r e s e a r c h e r s observed t h a t i n a s i g n i f i c a n t number of cases the plasma t u r b i d i t y was l e s s a f t e r e x e r c i s e than a f t e r r e s t i n g . The u n d e r l y i n g mechanism c a u s i n g the e f f e c t of e x e r c i s e on l i p i d and carbohydrate metabolism i s one which generates a great d e a l of d i s c u s s i o n . S e v e r a l systems have been pro-posed i n c l u d i n g those based on n u t r i t i o n a l , hormonal or nervous f a c t o r s . I s s e k u t z , M i l l e r and Rodahl (1966) conducted r a d i o i s o t o p i c s t u d i e s w i t h dogs i n o r d e r to attempt to shed more l i g h t on t h i s s u b j e c t . Since both plasma glucose and plasma f r e e f a t t y a c i d s can serve as f u e l , the authors attempted t o determine what f a c t o r s r e g u l a t e d the s u b s t r a t e supply d u r i n g e x e r c i s e . In a f i t dog d u r i n g strenuous exer-c i s e the f r e e f a t t y a c i d t u r n o v e r i n c r e a s e d but i n the u n f i t dog a decrease i n the f r e e f a t t y a c i d t u r n o v e r was observed. 32 The unanswered q u e s t i o n i s whether the r a p i d f o r m a t i o n o f l a c t i c a c i d or the inadequate oxygen supply c a u s i n g t h i s : r a p i d f o r m a t i o n reduces the f r e e f a t t y a c i d t u r n o v e r . None-t h e l e s s , whatever the reason or reasons f o r the m e t a b o l i c changes, p h y s i c a l e x e r c i s e has been o f f e r e d as an important f a c t o r to c o n s i d e r when e v a l u a t i n g the v a r i a t e s a s s o c i a t e d w i t h h y p e r l i p o p r o t e i n e m i a (Kannel, 1971 and A l b r i n k , 1974). Kannel, S o r l i e and McNamara (1971) r e p o r t e d from the f i n d i n g s of the Framingham study that the sedentary i n d i v i d -u a l s i n each age group had a coronary i n c i d e n c e almost twice t h a t of those who were at l e a s t moderately a c t i v e . However the p h y s i c a l a c t i v i t y assessment data of the study r e v e a l e d that p h y s i c a l a c t i v i t y c o n t r i b u t e s to coronary r i s k independ-ent of o t h e r f a c t o r s such as r e l a t i v e weight, b l o o d p r e s s u r e and c h o l e s t e r o l . The authors concluded t h a t : It i s time ... to c o n s i d e r e n g i n e e r i n g p h y s i c a l a c t i v i t y back i n t o d a i l y l i v i n g to c o u n t e r a c t the s l o t h and g l u t t o n y promoted by modern technology (p.260). The h y p o t h e s i s t h a t "men i n p h y s i c a l l y a c t i v e j obs have a lower i n c i d e n c e o f coronary heart d i s e a s e i n middle age than men i n p h y s i c a l l y i n a c t i v e j o b s " was proposed by M o r r i s and Crawford (1958). They r e p o r t e d the r e s u l t s of a study i n v e s t i g a t i n g the frequency of i s c h e m i c m y o c a r d i a l f i b r o s i s i n a sample of 3,800 middle-aged men dying from causes o t h e r than coronary heart d i s e a s e . Data o b t a i n e d d u r i n g the study supported the view that p h y s i c a l a c t i v i t y of work i s a pro-33 t e c t i o n a g a i n s t coronary heart d i s e a s e . I t would appear than men i n p h y s i c a l l y a c t i v e j o b s have l e s s coronary heart d i s e a s e d u r i n g middle-age, what d i s e a s e they have i s l e s s s e v e r e , and they develop i t l a t e r than men i n p h y s i c a l l y i n a c t i v e j o b s . Schaefer (1974) compared the serum c h o l e s t e r o l concen-t r a t i o n and t r i c e p s k i n f o l d t h i c k n e s s of Eskimos i n h u n t i n g camps w i t h those of t h e i r c o u n t e r p a r t s l i v i n g i n s e t t l e m e n t s . He found t h a t the h u n t i n g Eskimo aged e i g h t e e n t o t h i r t y - n i n e y e ars who was very a c t i v e had a s i g n i f i c a n t l y lower c h o l e s -t e r o l c o n c e n t r a t i o n and s k i n f o l d measurement than h i s counter-p a r t i n the s e t t l e m e n t . However the o l d e r hunter who became sedentary e x h i b i t e d s i m i l a r r e s u l t s to h i s s e t t l e m e n t counter-p a r t . The World H e a l t h O r g a n i s a t i o n r e p o r t on e x e r c i s e t e s t s i n r e l a t i o n t o c a r d i o v a s c u l a r f u n c t i o n (1968) s t a t e s t h a t : One f a c t o r t h a t may cause i n c r e a s e d i n c i d e n c e and p r e v a l e n c e of coronary heart d i s e a s e i n man i s a change i n h i s h a b i t u a l p h y s i c a l a c t i v i t y , which may be d e f i n e d as the p h y s i c a l workload to which a person i s u s u a l l y s u b j e c t e d d u r i n g h i s work and l e i s u r e . Both the t o t a l l o a d and the p a t t e r n o f such a c t i v i t y are of i n t e r e s t t o the i n v e s t i g a t o r . (P.24). From t h i s b r i e f review on p h y s i c a l a c t i v i t y i t can be seen t h a t energy e x p e n d i t u r e p l a y s an important r o l e i n the p r e v e n t i o n of c a r d i o v a s c u l a r d i s e a s e . The i n t e r r e l a t i o n s h i p 5 o f v a r i o u s components can a l s o be noted s i n c e p h y s i c a l a c t i v i t y can counter overweight and b e n e f i t serum l i p i d s , 34 blo o d p r e s s u r e and carbohydrate t o l e r a n c e . Hence the r e l a t i o n s h i p of p h y s i c a l a c t i v i t y to the presence o f h y p e r l i p o p r o t e i n e m i a i s of i n t e r e s t when i n v e s t i g a t i n g the f a c t o r s a s s o c i a t e d w i t h the presence of h y p e r l i p o p r o t e i n -emia . Family h i s t o r y of heart d i s e a s e H y p e r l i p o p r o t e i n e m i a may be f a m i l i a l and t h e r e f o r e an i n v e s t i g a t i o n o f the f a m i l y h i s t o r y has been suggested when r e s e a r c h i n g the presence of t h i s c o n d i t i o n . Glueck et a l . (1974) s t u d i e d c h i l d r e n from f a m i l i e s where one parent had a m y o c a r d i a l i n f a r c t (M.I.) before the age of 50. They documented f a m i l i a l hyperlipoproteinemia i n 85% of the M.I. k i n d r e d s , w i t h the predominant phenotypes being type I l a , and type IV h y p e r l i p o p r o t e i n e m i a . G o l d s t e i n et a l . (1973) suggested that a g e n e t i c a n a l y s i s of f a m i l i e s w i t h e l e v a t i o n s i n plasma l i p i d s would c o n t r i b u t e t o an un d e r s t a n d i n g of the i n h e r i t a n c e o f coronary a t h e r o s c l e r o s i s and u l t i m a t e l y p r o v i d e c l u e s f o r deter m i n i n g the u n d e r l y i n g b i o c h e m i c a l l e s i o n s . F r e d r i c k s o n et al. (1973) s t a t e d that "type I h y p e r l i p o -p r o t e i n e m i a i s n e a r l y always f a m i l i a l " w h i l e "type l i b may be f a m i l i a l and i f so i s a common i n h e r i t a b l e d i s o r d e r thought t o be t r a n s m i t t e d as an autosomal dominant t r a i t thus a f f e c t i n g both sexes e q u a l l y . " The authors a l s o suggested that "type I I I i s u s u a l l y f a m i l i a l and a p p a r e n t l y t r a n s m i t t e d 35 as a r e c e s s i v e t r a i t " whereas "type IV may be f a m i l i a l and i t i s l i k e l y t h a t s e v e r a l d i f f e r e n t mutations are respon-s i b l e . " Type l i b , being a combination of type I l a and type IV, may a l s o be f a m i l i a l as i s the case w i t h type V. Brown and G o l d s t e i n (1975) d i s c u s s e d the reasons f o r the e x i s t e n c e of f a m i l i a l h y p e r c h o l e s t e r o l e m i a . They pro-posed that the f a m i l i a l e n t i t y of h y p e r c h o l e s t e r o l e m i a i s due to a l a c k of H.M.G. coenzyme A reductase feedback con-t r o l . T h i s , they f e l t , was pro b a b l y caused by a c e l l membrane r e c e p t o r d e f e c t . Thus, i t would appear t h a t h y p e r l i p o p r o t e i n e m i a may be f a m i l i a l and consequently the i n h e r i t e d p r e d i s p o s i t i o n o f the s u b j e c t i s an important r i s k f a c t o r to c o n s i d e r when i n v e s t i g a t i n g the reasons f o r the presence o f h y p e r l i p o -p r o t e i n e m i a . Drugs Drugs have an important p o s i t i o n i n the treatment o f h y p e r l i p o p r o t e i n e m i a and t h e r e f o r e s h o u l d be c o n s i d e r e d i n any survey where plasma l e v e l s of t r i g l y c e r i d e s and c h o l e s -t e r o l are r e c o r d e d . C l o f i b r a t e i s perhaps the most commonly used h y p o l i p i d e m i c agent. Berkowitz (1971) c a r r i e d out a lo n g term study (8 years) on 50 h y p e r l i p i d e m i c p a t i e n t s u s i n g a d a i l y dosage of 2 grams o f c l o f i b r a t e . He observed a mean plasma c h o l e s t e r o l r e d u c t i o n o f 30% and a mean plasma t r i g l y c e r i d e r e d u c t i o n of 60% i n h i s s u b j e c t s . The mode o f a c t i o n of c l o f i b r a t e i s not completely c l e a r and s e v e r a l mechanicms have been suggested by Berkowitz i n c l u d i n g an i n h i b i t i o n of c h o l e s t e r o l s y n t h e s i s i n the l i v e r and i n t e s t i n e and a decrease i n the r e l e a s e of t r i g l y c e r i d e s i n t o the plasma. N i c o t i n i c a c i d may a l s o be used to decrease plasma t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s . C a r l s o n and Oro (1973) from t h e i r work suggested t h a t removal from b l o o d of serum t r i g l y c e r i d e s i n chylomicrons and i n very low d e n s i t y l i p o -p r o t e i n s may be improved w i t h n i c o t i n i c a c i d . Other l i p i d l o w e r i n g drugs which may be used i n c l u d e c h o l e s t y r a m i n e , d e x t r o t h y r o x i n sodium, neomycin and a m i n o s a l i c y l i c a c i d a l l o f which i n c r e a s e the r a t e of very low d e n s i t y l i p o p r o t e i n removal and are thus most e f f e c t i v e i n d i s t u r b a n c e s of low d e n s i t y l i p o p r o t e i n c l e a r a n c e (Levy, 1973). T h e r e f o r e when c o n d u c t i n g any survey where serum l e v e l s of t r i g l y c e r i d e and c h o l e s t e r o l are noted, the s u b j e c t ' s m e d i c a t i o n s h o u l d be i n v e s t i g a t e d . E l i m i n a t i o n from the study of those s u b j e c t s on l i p i d - l o w e r i n g drugs would then be n e c e s s a r y . Age In a study u s i n g 276 men and women aged 20-69 years l i v i n g i n London, Lewis et a l . (1974) found that the serum c h o l e s t e r o l and t r i g l y c e r i d e c o n c e n t r a t i o n s i n c r e a s e d w i t h 37 age, r e a c h i n g the h i g h e s t c o n c e n t r a t i o n i n the 50-59 year age-group and d e c r e a s i n g i n the 60-69 year group. The r e l a t i o n s h i p of age to serum l i p i d l e v e l s i s important as the c o n c e n t r a t i o n o f a l l l i p i d s and l i p o p r o t e i n s appear t o be a f f e c t e d by age. Levy (1973) i n h i s review o f the d i a g n o s i s and treatment of h y p e r l i p o p r o t e i n e m i a s t a t e d : Remember that the c o n c e n t r a t i o n o f a l l l i p i d s and l i p o p r o t e i n s i n c r e a s e s w i t h age. A normal value f o r c h o l e s t e r o l and/or l i p o p r o t e i n c o n c e n t r a t i o n i n a 40 or 50-year o l d person might be q u i t e a l a r m i n g i n a 10-year o l d c h i l d (p.649). Both the i n c i d e n c e of type IV h y p e r l i p o p r o t e i n e m i a and the plasma c o n c e n t r a t i o n of serum t r i g l y c e r i d e s i n c r e a s e s w i t h age ( F r e d r i c k s o n , Levy and Lees, 1967). T h e r e f o r e , although ageing cannot be prevented i t s h o u l d be c o n s i d e r e d when s t u d y i n g the f a c t o r s a f f e c t i n g the presence o f h y p e r l i -p oproteinemia . Sherwin (1974) suggested t h a t : Men have a much g r e a t e r r i s k than women i n e a r l y middle age ... the r i s k w i t h i n c r e a s i n g age r i s e s much more s t e e p l y i n women than i n men so th a t the r a t e s converge i n o l d age (p.82). Glucose i n t o l e r a n c e It has been suggested that glucose i n t o l e r a n c e may pre -d i s p o s e to the development of ischemic heart d i s e a s e (Report o f the A d v i s o r y Panel of the B r i t i s h Committee on Me d i c a l Aspects of Food P o l i c y ( N u t r i t i o n ) on Diet i n r e l a t i o n t o C a r d i o v a s c u l a r and C e r e b r o v a s c u l a r D i s e a s e , 1975). 38 T h e r e f o r e the method by which glucose i n t o l e r a n c e a f f e c t s the presence of c a r d i o v a s c u l a r d i s e a s e i s of i n t e r e s t , p a r t i c u l a r l y the r e l a t i o n s h i p between glucose i n t o l e r a n c e and h y p e r l i p o p r o t e i n e m i a . F r e d r i c k s o n , Levy and Lees (1967) observed that i n t h e i r e x p e r i e n c e the i n c i d e n c e of abnormal glucose t o l e r a n c e i n s u b j e c t s w i t h type IV h y p e r l i p o p r o t e i n e m i a exceeded 90%. Glucose i n t o l e r a n c e may be demonstrated by d i a b e t e s , a t r a c e or more of sugar i n the u r i n e o r a c a s u a l ( n o n - f a s t i n g ) whole blo o d glucose l e v e l of 120 mg./lOO ml. o r more (American Heart A s s o c i a t i o n , 1973). O l e f s k y , Reaven and Farquhar (1974b) s t u d i e d the r o l e of o b e s i t y i n c a u s i n g hyperglycemia, h y p e r l i p e m i a , hyper-i n s u l i n e m i a and i n s u l i n r e s i s t a n c e . The h y p o t h e s i s they used as the b a s i s of t h e i r r e s e a r c h was that i n s u l i n r e s i s -tance l e a d s to h y p e r i n s u l i n e m i a which l e a d s to a c c e l e r a t e d h e p a t i c t r i g l y c e r i d e p r o d u c t i o n which i n t u r n l e a d s to e l e v a t e d plasma t r i g l y c e r i d e c o n c e n t r a t i o n s . F o l l o w i n g weight reduc-t i o n among t h e i r s u b j e c t s , the r e s e a r c h e r s noted a s i g n i f i c a n t decrease i n the i n s u l i n and glucose responses to the o r a l g l ucose t o l e r a n c e t e s t . The e f f e c t of o b e s i t y on hyper-g l y c e m i a , h y p e r l i p e m i a , h y p e r i n s u l i n e m i a and i n s u l i n r e s i s -tance i l l u s t r a t e s the complexity of the f a c t o r s i n v o l v e d i n the presence o f h y p e r l i p o p r o t e i n e m i a . Carbohydrate, l i p i d and l i p o p r o t e i n metabolism are c l o s e l y r e l a t e d ( S c h o n f i e l d et a l . , 1974) and t h e r e f o r e i t would seem t o f o l l o w t h a t changes i n one of these f a c t o r s would auto-m a t i c a l l y l e a d t o changes i n the metabolism of the o t h e r two components. Rodger, Squires and Du (1971) s t u d i e d changes i n plasma i n s u l i n r e l a t e d t o the type o f d i e t a r y carbohydrate i n overweight h y p e r l i p i d e m i c male p a t i e n t s . They observed t h a t when 75% of the d i e t a r y carbohydrate was d e r i v e d from food c o n t a i n i n g p o l y s a c c h a r i d e s , the mean plasma i n s u l i n response to o r a l glucose was decreased r e l a -t i v e to that seen f o l l o w i n g complementary d i e t s p r o v i d i n g carbohydrate mainly as simple s u g a r s . From t h e i r s t u d i e s the authors concluded t h a t the type of d i e t a r y carbohydrate may c o n t r i b u t e t o the a b n o r m a l i t i e s of i n s u l i n s e c r e t i o n known to e x i s t i n s t a t e s o f o b e s i t y and glucose i n t o l e r a n c e . A l b r i n k (1974) suggested that " i t i s the endogenous t r i g l y c e r i d e s t h at have been i m p l i c a t e d i n a t h e r o s c l e r o t i c c a r d i o v a s c u l a r d i s e a s e and that are a s s o c i a t e d w i t h m i l d o b e s i t y , m i l d d i a b e t e s and h y p e r i n s u l i n e m i a . " T h e r e f o r e glucose i n t o l e r a n c e as d e s i g n a t e d by d i a b e t e s m e l l i t u s , hyperglycemia or abnormal u r i n e g l u c o s e l e v e l s s h o u l d be regarded as a r i s k f a c t o r a s s o c i a t e d w i t h the presence of h y p e r l i p o p r o t e i n e m i a . Anthropometry A d i s c u s s i o n r e l a t e d to the r e l a t i o n s h i p between o b e s i t y and plasma l i p i d s has a l r e a d y been conducted under the head-i n g o f N u t r i t i o n a l P r a c t i c e s - T o t a l c a l o r i e s . The use of the 40 h e i g h t , weight, ponderal index, s k i n f o l d t h i c k n e s s and arm c i r c u m f e r e n c e measurements to determine anthropometric s t a t u s w i l l be d i s c u s s e d i n the f o l l o w i n g s e c t i o n . Methodology f o r Assessment of N u t r i t i o n a l P r a c t i c e s and Anthropometric Status Anthropometric Status The measurement of h e i g h t and weight can be examined c o l l e c t i v e l y as the ponderal index (Height ( i n . ) / cube r o o t of weight ( l b s . ) ) . T h i s i s an assessment of weight i n r e l a t i o n t o h e i g h t . The low index i s an i n d i c a t o r of excess body weight whereas a high index i s an i n d i c a t o r of leanness ( N u t r i t i o n Canada, 1973). A c c o r d i n g to J e l l i f f e (1966) weight i s a key anthropometric measurement which s h o u l d be combined w i t h i n f o r m a t i o n r e l a t e d to h e i g h t , frame s i z e , p r o p o r t i o n s of f a t , muscle and bone and the presence of p a t h o l o g i c a l weight (eg. edema). The t r i c e p s k i n f o l d t h i c k n e s s i s an i n d i c a t o r o f the development of subcutaneous f a t ( F r i s a n c h o , 1974). Standards f o r h e i g h t and weight are not s u f f i c i e n t to d e t e r -mine the degree o f leanness o r o b e s i t y e x h i b i t e d by an i n d i v i d u a l and t h e r e f o r e the amount of subcutaneous f a t p r e s e n t as measured by the s k i n f o l d t h i c k n e s s may be used f o r a more d i r e c t i n d i c a t i o n (Tanner and Whitehouse, 1962). These r e s e a r c h e r s suggested t h a t the s k i n f o l d t h i c k n e s s c o r r e l a t e s h i g h l y w i t h the f a t - w i d t h as measured by x - r a y . 41 J e l l i f f e (1966) suggested that the s k i n f o l d t h i c k n e s s i s a good method of a n a l y s i s of d i s t r i b u t i o n and amount o f human subcutaneous f a t and hence c a l o r i c r e s e r v e s . He a d v i s e d t h a t : The most a p p r o p r i a t e " p i n c h " s i t e s depend on the purpose of the study, the age of the p o p u l a t i o n examined ( f a t d i s t r i b u t i o n v a r i e s w i t h age, even i n c h i l d h o o d ) , sex, p r e c i s i o n i n l o c a t i n g the p a r t i c u l a r s i t e , the r e l a t i v e homogeneity of the t h i c k n e s s o f the l a y e r of f a t and s k i n i n a g i v e n r e g i o n , and the ease of otherwise of a c c e s s i b i l i t y when problems of u n d r e s s i n g and modesty e x i s t (p.72). L o c a l standards s h o u l d be used when e v a l u a t i n g the s k i n f o l d measurements as i t has been suggested that sex d i f f e r e n c e s , muscle hypertrophy, c l i m a t i c c o n d i t i o n s and the f a t content of the d i e t may a l l c o n t r i b u t e to a f a l s e measurement. S e v e r a l s i t e s may be chosen f o r the s k i n f o l d t h i c k n e s s measurement i n c l u d i n g the t r i c e p s , s u b s c a p u l a r and supra i l i a c s i t e s ( J e l l i f f e , 1966). Durn i n and Rahaman (1967) s t u d i e d 105 young a d u l t s and 86 a d o l e s c e n t s . Measurements of h e i g h t ( s t a n d i n g and s i t t i n g ) , b i - a c r o m i a l and b i - i l i a c diameters, g i r t h of the upper arm, upper t h i g h and c a l f , s k i n f o l d t h i c k n e s s and body d e n s i t y were re c o r d e d . The r e s e a r c h e r s d i s c o v e r e d a h i g h c o r r e l a t i o n between the s k i n f o l d measurement and the body d e n s i t y . The t r i c e p s k i n f o l d t h i c k n e s s i s not o n l y u s e f u l as an index of c a l o r i c r e s e r v e s but enables the u n d e r l y i n g mid-upper arm muscle c i r c u m f e r e n c e to be c a l c u l a t e d . Muscle mass may be a s s e s s e d by d i r e c t p h y s i c a l anthropometry of a limb -42 e i t h e r the m i d - c a l f or mid-upper arm. From the arm c i r -cumference and the t r i c e p s k i n f o l d t h i c k n e s s measurement i t i s p o s s i b l e to c a l c u l a t e the i n n e r c i r c l e - the mid-arm-muscle c i r c u m f e r e n c e ( J e l l i f f e , 1966). Thus the h e i g h t , weight, ponderal index, amount of sub-cutaneous f a t ( s k i n f o l d t h i c k n e s s ) and the amount of muscle mass (arm c i r c u m f e r e n c e ) t o g e t h e r i n d i c a t e the anthropometric s t a t u s o f the i n d i v i d u a l . N u t r i t i o n a l P r a c t i c e s S e v e r a l methods have been used f o r the c o l l e c t i o n of food consumption data e.g. f o o d balance s h e e t s , food accounts, the weight method, q u e s t i o n n a i r e s , c h e m i c a l a n a l y s i s and i n t e r v i e w i n g ( d i e t h i s t o r y , seven-day food r e c o r d and twenty-f o u r hour r e c a l l ) . The purpose of the survey determines the a c c u r a c y o f the consumption data needed which i n t u r n a f f e c t s the c h o i c e of method. Food balance sheets are n o r m a l l y used i n o r d e r t o d e t e r -mine the consumption f i g u r e s of the whole p o p u l a t i o n whereas the f o o d accounts method i s o f t e n employed when s t u d y i n g the f o o d consumption o f people l i v i n g i n i n s t i t u t i o n s . The weighing method p r e s e n t s a c c u r a t e data on food con-sumption. T h i s method r e q u i r e s the weighing of a l l food-s t u f f s used f o r the p r e p a r a t i o n of the meal, the cooked food, amounts eaten at meals, the p l a t e waste and the d i s c a r d e d f o o d (Pekkarinen, 1970). However the time and o r g a n i s a t i o n 43 r e q u i r e d f o r t h i s method l i m i t s the s i t u a t i o n s i n which i t can be used. Chemical a n a l y s i s p r o v i d e s p r e c i s e data on the a c t u a l i n t a k e s of v a r i o u s n u t r i e n t s but due to the expense i n v o l v e d may o n l y be used f o r very s m a l l s u r v e y s . However chemical a n a l y s i s may be used to c o n t r o l the r e l i a b i l i t y o f r e s u l t s o b t a i n e d by c a l c u l a t i o n s (Pekkarinen, 1970). The p r i n c i p l e of the q u e s t i o n n a i r e method i s very s i m i l a r to t h a t of the d i e t a r y h i s t o r y apart from the f a c t that no i n t e r v i e w e r i s r e q u i r e d . Balogh et a l . (1968) developed a d i e t a r y q u e s t i o n n a i r e f o r an i s c h e m i c h e a r t d i s e a s e survey. They t e s t e d the v a l i d i t y of t h i s method a g a i n s t both the d i e t a r y h i s t o r y and a combined week's r e c o r d and weighing of r e p r e s e n t a t i v e f o o d items. The authors con-cluded from t h e i r r e s u l t s t h a t the q u e s t i o n n a i r e i s a p r a c t i c a l t o o l f o r the assessment of d i e t a r y i n t a k e . I n t e r v i e w i n g i s perhaps the most commonly p r a c t i s e d method f o r the c o l l e c t i o n of f o o d consumption data on an i n d i v i d u a l b a s i s . V a r i a t i o n s of t h i s method i n c l u d e the d i e t a r y h i s t o r y , seven-day or three-day food r e c o r d and the twenty-four hour food r e c a l l . A c c o r d i n g to Young (1959) s e v e r a l p o i n t s s h o u l d be c l a r i f i e d b e f o r e the i n t e r v i e w i s conducted. The f i r s t f a c t o r to be determined i s the purpose o f the i n t e r v i e w . Is i t to o b t a i n q u a n t i t a t i v e i n f o r m a t i o n , q u a l i t a t i v e 44 i n f o r m a t i o n or s e a r c h i n g i n f o r m a t i o n on the d i e t a r y h a b i t s o f the i n d i v i d u a l ? Secondly, the i n t e r v i e w e r s h o u l d be c a r e f u l l y chosen as "competent d i e t a r y i n t e r v i e w i n g i s a h i g h l y s k i l l e d p r o c e s s . " The time element i s extremely important i n c l u d i n g both the l e n g t h of the i n t e r v i e w and the time of day at which i t i s conducted. C h a r l o t t e Young (1959) f e e l s t h a t i t i s not p o s s i b l e to o b t a i n meaningful i n f o r m a t i o n i n l e s s than t h i r t y t o f o u r t y - f i v e minutes. T h i s i m p r e s s i o n i s s i m i l a r to that h e l d by Burke (1947) who s t a t e s t hat "the i n t e r v i e w s h o u l d consume approximately one hour." F o u r t h l y , the environment i n which the i n t e r v i e w i s conducted c o n t r i b u t e s to the success of f a i l u r e of the exer-c i s e as a p r i v a t e and calm atmosphere i s d e s i r a b l e . F i n a l l y , the technique to be employed and that data c o l l e c t i o n i n s t r u m e n t s to be used s h o u l d be chosen p r i o r to the i n t e r -view. Burke (1947) emphasizes t h a t the average d i e t a r y i n t a k e over a c o n s i d e r a b l e p e r i o d o f time can o n l y be o b t a i n e d by the d i e t a r y h i s t o r y method. In o r d e r to improve the accuracy of the d i e t a r y h i s t o r y she suggests that a c r o s s -check be made i n o r d e r to v e r i f y and c l a r i f y the i n f o r m a t i o n g i v e n i n the u s u a l i n t a k e . As a f u r t h e r method of c o r r o b o r a -t i o n the three-day r e c o r d may a l s o be used. Young et a l . (1952) conducted a comparison of the d i e t a r y h i s t o r y v e r s u s twenty-four hour r e c a l l and the seven-day r e c o r d versus twenty-four hour r e c a l l method of d i e t a r y study. 45 They found t h a t the twenty-four hour r e c a l l and the seven-day r e c o r d d i d not give the same estimates of i n t a k e of i n d i v i d u a l s as the d i e t a r y h i s t o r y and t h e r e f o r e concluded that these two methods c o u l d not be used i n t e r c h a n g e a b l y to d e s c r i b e the i n t a k e of i n d i v i d u a l s but c o u l d perhaps be i n t e r c h a n g e d when e s t i m a t i n g group i n t a k e s . The v a l i d i t y of the twenty-four hour r e c a l l method as a d i e t a r y t o o l was s t u d i e d by L i n u s s o n , Sanjur and E r i c k s o n (1974). E i g h t y - s i x l a c t a t i n g women i n C o r n e l l M e d i c a l Centre were employed as s u b j e c t s . From the r e s u l t s of the survey the authors concluded t h a t : The r e c a l l method appears f a i r l y a c c u r a t e f o r q u a l i t a t i v e e s t i m a t i o n of average f o r a p o p u l a t i o n group but not h i g h l y v a l i d f o r a s c e r t a i n i n g q u a n t i t y of food consumed (p.277). Pekkarinen (1970) suggested t h a t twenty-four hour r e c a l l and d i e t h i s t o r y can be used t o r e p l a c e each o t h e r i n group surveys i f the sample i s l a r g e and the d a i l y and s e a s o n a l v a r i a t i o n s of the d i e t are s m a l l . Thus, i t would appear from the l i t e r a t u r e t h a t s e v e r a l methods may be used f o r the c o l l e c t i o n of f o o d consumption data and that the a p p l i c a t i o n of more than one of these methods may i n c r e a s e the a c c u r a c y of the i n f o r m a t i o n . Summary The b r i e f review of l i t e r a t u r e i n c l u d e d i n t h i s c h a p t e r i l l u s t r a t e s the vast amount of knowledge s t i l l r e q u i r e d to 46 determine the reasons f o r the h i g h i n c i d e n c e of c a r d i o v a s c u l a r d i s e a s e i n our p o p u l a t i o n . It can be seen from t h i s resume that the p i c t u r e i s a complex one. No one f a c t o r i s s o l e l y r e s p o n s i b l e and even g e o g r a p h i c a l d i f f e r e n c e s may a f f e c t n a t i o n a l s t a t i s t i c s of c a r d i o v a s c u l a r d i s e a s e , i l l u s t r a t i n g the p o t e n t i a l dangers of assuming t h a t the r e s u l t s o f i n v e s t i -g a t i o n s made i n one c o u n t r y n e c e s s a r i l y apply i n another (Report of the A d v i s o r y Panel of the B r i t i s h Committee on M e d i c a l Aspects o f Food P o l i c y ( N u t r i t i o n ) on D i e t i n r e l a t i o n t o C a r d i o v a s c u l a r and C e r e b r o v a s c u l a r Disease, 1975). Many of the s c i e n t i f i c papers r e p o r t e d here have d i s -cussed the e f f e c t of one p a r t i c u l a r f a c t o r r a t h e r than con-s i d e r i n g a l l of the p r e d i s p o s i n g components. L i m i t e d r e s e a r c h has been r e p o r t e d on the nature o f the i n t e r r e l a t i o n -s h i p s between these c o n s t i t u e n t s and the presence of h y p e r l i -p o p r o t e i n e m i a . S i m i l a r l y , the e f f e c t of v a r i o u s n u t r i e n t s on the t u r n o v e r o f plasma t r i g l y c e r i d e s i n normal and hyper-l i p e m i a s u b j e c t s i s , as y e t , p o o r l y understood. Kannel (1971) s t a t e d : What we know now about the e v o l u t i o n of a t h e r o s c l e r o s i s i n d i c a t e s t h at any p r o p h y l a c t i c e f f o r t s h o u l d b e g i n as e a r l y i n l i f e as p o s s i b l e . Once begun, i t must remain a continuous l i f e t i m e endeavour (p.3). A p r e v e n t a t i v e approach i s o b v i o u s l y the p o s i t i v e method of d e a l i n g w i t h a major p u b l i c h e a l t h problem. However i n o r d e r to p r a c t i s e t h i s technique s o l i d knowledge of the means of p r e v e n t i o n must be w i t h i n our r e a c h . A vast amount of 47 s c i e n t i f i c work has been undertaken i n o r d e r to achieve t h i s knowledge but, as y e t , we do not have a f u l l u n derstanding of the cause or causes of h y p e r l i p o p r o t e i n e m i a . S e v e r a l r i s k f a c t o r s have been suggested i n the p r e c e d i n g review. Apart from age, sex and g e n e t i c coding a l l of these f a c t o r s are c l o s e l y a s s o c i a t e d w i t h our l i f e - s t y l e . To manipulate the l i f e - s t y l e of a whole p o p u l a t i o n i s a l a r g e and seemingly near i m p o s s i b l e u n d e r t a k i n g . T h e r e f o r e we must have d e f i n i t e evidence t h a t f a c t o r s such as smoking, a l c o h o l consumption, o b e s i t y , l a c k of e x e r c i s e , a low P:S r a t i o i n the d i e t o r an excess consumption of sucrose or f a t are indeed a s s o c i a t e d w i t h h y p e r l i p o p r o t e i n e m i a . Once t h i s evidence i s o b t a i n e d a l a r g e s c a l e method of p u b l i c h e a l t h e d u c a t i o n must be commenced i n o r d e r to reduce the unnecessary l o s s of l i f e o c c u r r i n g i n Canada today as a r e s u l t o f c a r d i o v a s c u l a r d i s e a s e . Speckmann (1975) s t a t e s : Not o n l y must r e s e a r c h e r s continue to f i n d new informa - r t i o n c o n c e r n i n g t h i s d i s e a s e e n t i t y , but they must seek to pass the knowledge thus gained to those who have assumed the r o l e of watchdogs over the n a t i o n ' s heart h e a l t h . S t u d i e s r e f l e c t i n g the i n f l u e n c e of ... smoking and o t h e r r i s k f a c t o r s ... have not been ade-q u a t e l y brought t o the p u b l i c ' s a t t e n t i o n (p.33). CHAPTER I I I DESIGN OF THE STUDY T h i s study i s designed t o i n v e s t i g a t e the r e l a t i o n s h i p of n u t r i t i o n a l p r a c t i c e s and r e l a t e d demographic v a r i a b l e s to the presence o f h y p e r l i p o p r o t e i n e m i a i n males aged t h i r t y to s i x t y years who were admitted to St. P a u l ' s H s o p i t a l f o r c a r d i a c c a t h e t e r i z a t i o n . Research Design An a s s o c i a t i o n a l study was conducted to i n v e s t i g a t e the r e l a t i o n s h i p o f c e r t a i n c r i t e r i a to the presence of h y p e r l i p o p r o t e i n e m i a . The c r i t e r i o n v a r i a b l e s (Baker and Schutz, 1972) measured i n t h i s study were: 1. F a s t i n g serum t r i g l y c e r i d e l e v e l 2. F a s t i n g serum c h o l e s t e r o l l e v e l The v a r i a t e s (Baker and Schutz, 1972) were c a t e g o r i s e d as: 1. N u t r i t i o n a l p r a c t i c e s 2. Demographic f a c t o r s 3. Anthropometry The nature of the r e l a t i o n s h i p between the c r i t e r i o n v a r i a b l e s and the v a r i a t e s and amongst the v a r i a t e s them-s e l v e s were i n v e s t i g a t e d a c c o r d i n g t o the model o u t l i n e d i n F i g u r e 1. 48 STARCH PHYSICAL ACTIVITY PERCENT SUCROSE PERCENT FAT CALORIES BODY PERCENT SMOKING WEIGHT <—> ALCOHOL PRESENCE OF HYPERLIPOPROTEINEMIA r \ \ \ PHYSICAL ACTIVITY P:S (RATIO PERCENT STARCH F i g u r e 1. The nature o f the r e l a t i o n s h i p between the c r i t e r i o n v a r i a b l e s and the v a r i a t e s and amongst the v a r i a t e s themselves. In t h i s design-t p r e f e r s to an i n t e r r e l a t i o n s h i p , > r e f e r s to a p o s i t i v e r e l a t i o n s h i p , and — — — p r e f e r s t o a ne g a t i v e r e l a t i o n s h i p . 50 P o p u l a t i o n and Sample The p o p u l a t i o n i n v e s t i g a t e d i n t h i s study were men aged t h i r t y to s i x t y years who were admitted to the C l i n i c a l I n v e s t i g a t i o n Unit at St. Paul's H o s p i t a l f o r c a r d i a c c a t h -e t e r i z a t i o n under the care of Dr's. A Dodek, J Boone, D P e r e t z and D Kavanagh-Gray. Scheduled i n t e r v i e w s were conducted w i t h p r i o r p e r m i s s i o n of the medical and n u r s i n g s t a f f and t h e r e f o r e o n l y those s u b j e c t s able to p a r t i c i p a t e were i n c l u d e d i n the study. Ninety-one s u b j e c t s were i n v o l v e d i n the survey. Data C o l l e c t i o n Data c o l l e c t i o n instruments (see Appendix A) were developed f o r measurement of the t h r e e v a r i a t e s . Three methods of data c o l l e c t i o n were used ( F i g u r e 2 ) . The i n t e r -view was based on the method suggested by Young (1959). Approximately one hour was used f o r t h i s i n t e r v i e w on the day of the s u b j e c t ' s admission to h o s p i t a l . N u t r i t i o n a l P r a c t i c e s A three-day food r e c o r d form (see Appendix A) was mai l e d to each s u b j e c t (whenever p o s s i b l e ) at l e a s t one week p r i o r t o t h e i r i n t e n d e d admission to h o s p i t a l . Where n o t i c e of the p a t i e n t ' s admission was not r e c e i v e d by the r e s e a r c h e r i n time to contact the s u b j e c t , a twenty-four hour d i e t a r y THREE-DAY DIET RECORD NUTRITIONAL PRACTICES ANTHROPOMETRY DEMOGRAPHIC FACTORS ST. PAUL'S - CRITERION HOSPITAL s VARIABLES PLUS — 7 LABORATORY FASTING BLOOD GLUCOSE F i g u r e 2. Data c o l l e c t i o n model. 52 r e c a l l was o b t a i n e d d u r i n g the i n t e r v i e w . The three-day food r e c o r d or twenty-four hour d i e t a r y r e c a l l was cross-checked w i t h a d i e t a r y h i s t o r y taken d u r i n g the i n t e r v i e w w i t h the s u b j e c t . The instrument used f o r the d i e t a r y h i s t o r y was based on the method d e s c r i b e d by Burke (1947). The i n f o r m a t i o n o b t a i n e d from the food consumption data i n c l u d e d : 1. Sucrose as percent t o t a l carbohydrate i n the d i e t . 2. S t a r c h as percent t o t a l carbohydrate i n the d i e t . 3. P:S r a t i o . 4. T o t a l c a l o r i c i n t a k e . 5. Fat as percent t o t a l d i e t a r y c a l o r i e s . 6. A l c o h o l as percent t o t a l c a l o r i e s i n the d i e t . Data r e l a t i n g to P:S r a t i o , t o t a l c a l o r i c i n t a k e , and t o t a l f a t consumption were se c u r e d w i t h the a i d of the General N u t r i e n t A n a l y s i s Programme of the School of Home Economics, U n i v e r s i t y of B r i t i s h Columbia. The i n t a k e of s u c r o s e , s t a r c h and a l c o h o l was not a v a i l a b l e through t h i s programme. A l c o h o l consumption was c a l c u l a t e d by the r e s e a r c h e r w i t h the a i d of composition t a b l e s produced by Bowes and Church (1969). Hardinger, Swarner and Crooks (1965) p u b l i s h e d composition t a b l e s i n which both a v a i l a b l e and u n a v a i l a b l e carbohydrate f i g u r e s are i n c l u d e d . These t a b l e s , although u s e f u l , are not e x t e n s i v e . T h e r e f o r e the sucrose and s t a r c h content of some foods had to be e s t i m a t e d from the carbohydrate 53 content of these foods i n c l u d e d e i t h e r i n the Bowes and Church or the Department of N a t i o n a l Health and Welfare (1973) com-p o s i t i o n t a b l e s . A l i s t of these e s t i m a t i o n s i s i n c l u d e d i n Appendix B. Demographic F a c t o r s The i n f o r m a t i o n r e q u i r e d was o b t a i n e d d u r i n g the one i n t e r v i e w conducted between the r e s e a r c h e r and the s u b j e c t . The extent of p h y s i c a l a c t i v i t y h a b i t u a l l y undertaken by the s u b j e c t was asse s s e d w i t h the a i d of a q u e s t i o n n a i r e (Health and Welfare Canada, 1973). The r e s u l t s were s c o r e d f o r data a n a l y s i s (Table 1 ) . TABLE I SCORING SYSTEM FOR PHYSICAL ACTIVITY PHYSICAL ACTIVITY SCORE SEDENTARY work and l e i s u r e l e s s than 5 f l i g h t s of s t a i r s o r \ m i l e walking each day. 1 LOW MODERATE some a c t i v i t y , work and l e i s u r e between 5 and 15 f l i g h t s of s t a i r s or 0.5 - 1.5 m i l e s walk-i n g or comparable d a i l y a c t i v i t y . 2 HIGH MODERATE programmed e x e r c i s e 4 times/week o r 1.5 - 2 m i l e s walking or 15-20 f l i g h t s of s t a i r s or com-par a b l e d a i l y a c t i v i t y . 3 VIGOROUS g r e a t e r than moderate. 4 54 I n f o r m a t i o n p e r t a i n i n g to smoking, f a m i l y h i s t o r y o f heart d i s e a s e , age and medications taken by the s u b j e c t were o b t a i n e d d u r i n g the i n t e r v i e w . T h i s i n f o r m a t i o n was recor d e d f o r data a n a l y s i s . Smoking and age were r e p o r t e d on a con-t i n u o u s s c a l e w h i l e f a m i l y h i s t o r y was t r e a t e d as a d i c h o t o -mous v a r i a b l e (l=no and 2=yes). I f the s u b j e c t was c u r r e n t l y t a k i n g a hy p o l i p e m i c agent e x c l u s i o n of that s u b j e c t from the survey was necessar y . The f a s t i n g blood glucose l e v e l was ob t a i n e d by S t . Pa u l ' s H o s p i t a l L a b o r a t o r y u s i n g the Technicon Au t o - a n a l y z e r method N-166 f o r simultaneous glucose/BUN. Anthropometry The h e i g h t ( i n cms.) and weight ( i n kgs.) were o b t a i n e d by the r e s e a r c h e r d u r i n g the one i n t e r v i e w conducted w i t h the s u b j e c t . C o n t i n e n t a l H e a l t h 0 Meter balance s c a l e s were used. T h i s i n f o r m a t i o n was c o n v e r t e d by computer to the po n d e r a l index ( N u t r i t i o n Canada, 1973). The s k i n f o l d t h i c k n e s s was measured d u r i n g the i n t e r v i e w u s i n g Harpender S k i n f o l d C a l i p e r s . One measurement was taken i . e . t r i c e p s , a c c o r d i n g t o the d i r e c t i o n s s e t out by Weiner and L a u r i e (1969). The arm cir c u m f e r e n c e measurement was o b t a i n e d at the same time. A l l of the anthropometric measurements were re c o r d e d on a c o n t i n u -ous s c a l e . 55 C r i t e r i o n V a r i a b l e s I n f o r m a t i o n r e l e v a n t to the c r i t e r i o n v a r i a b l e s was s e c u r e d i n the f o l l o w i n g manner; F a s t i n g serum t r i g l y c e r i d e l e v e l T h i s was o b t a i n e d from the r e s u l t s of a n a y l s i s of the s u b j e c t ' s serum by St. P a u l ' s H o s p i t a l l a b o r a t o r y . The Gemsaec automatic a n a l y z e r procedure f o r t r i g l y c e r i d e c a l -c u l a t i o n was used. F a s t i n g serum c h o l e s t e r o l l e v e l T h i s was o b t a i n e d from the r e s u l t s of a n a l y s i s of the s u b j e c t ' s serum by S t . P a u l ' s H o s p i t a l l a b o r a t o r y . The Technicon a u t o - a n a l y z e r method N-37a f o r t o t a l c h o l e s t e r o l by continuous f i l t e r was used. Procedure Ninety-one i n t e r v i e w s were conducted between May 1 s t . and October 16th, 1975. The s u b j e c t s were admitted to St. Paul's H o s p i t a l from Sunday to Thursday every week. Where n o t i c e of the p a t i e n t ' s admission had been o b t a i n e d i n advance of admission, i n f o r m a t i o n d e s c r i b i n g the survey (Appendix A) was m a i l e d to the s u b j e c t t o g e t h e r w i t h the three-day food r e c o r d forms. T h i s i n f o r m a t i o n was t r a n s m i t t e d to the remaining s u b j e c t s at the time of the i n t e r v i e w . F o l l o w i n g admission to St. P a u l ' s H o s p i t a l the p a t i e n t was v i s i t e d by the i n t e r v i e w e r and p e r m i s s i o n o b t a i n e d to secure 56 the r e q u i r e d d ata. Only one i n d i v i d u a l d e c l i n e d the i n v i -t a t i o n to be i n c l u d e d i n the study. A f t e r c o l l e c t i o n of the anthropometric and demographic ( e x c l u d i n g f a s t i n g b l o o d glucose) i n f o r m a t i o n , the twenty-four hour d i e t a r y r e c a l l was o b t a i n e d or the three-day food r e c o r d d i s c u s s e d . A d i e t a r y h i s t o r y was then s e c u r e d . At t h i s time r e q u i s i t i o n s f o r the f a s t i n g b l o o d g l u c o s e , f a s t i n g serum t r i g l y c e r i d e and f a s t i n g serum c h o l e s t e r o l l e v e l s were sent to the l a b o r a t o r y . The p a t i e n t was i n s t r u c t e d to f a s t f o r twelve hours p r i o r to c o l l e c t i o n o f the bloo d by the l a b o r a t o r y p e r s o n n e l the f o l l o w i n g morning. R e s u l t s of the l a b o r a t o r y a n a l y s i s were o b t a i n e d from the p a t i e n t ' s m e d i c a l ch a r t at a l a t e r date. The data c o l l e c t e d was coded and submitted to the Key-punching S e r v i c e of the Computing Centre at the U n i v e r s i t y of B r i t i s h Columbia, f o r key-punching. In o r d e r to f a c i l i t a t e completion o f the study a time schedule was designed. T h i s schedule f o l l o w s : Schedule State 1 - P l a n n i n g and P r e p a r a t i o n 1. Design study February -March 1975 2. O b t a i n p e r m i s s i o n from U.B.C. Committee f o r r e s e a r c h w i t h human s u b j e c t s . March 1975 3. Develop and p r i n t i n t e r v i e w forms i . e . d i e t a r y h i s t o r y and i n t e r -viewer's r e c o r d i n g forms. 57 Stage 1 (continued) Develop coding sheets 4. 5. 6. 7. 8. F a m i l i a r i z e ward s t a f f w i t h the procedure of data c o l l e c t i o n F a m i l i a r i z e M e d i c a l Records Department w i t h study-P r a c t i c e data c o l l e c t i o n procedure Check wi t h St. P a u l ' s l a b o r a t o r y r e g a r d i n g 'method of a n a l y s i s 9. M a i l l e t t e r s to the C a r d i o l o g i s t s A p r i l 1975 Stage 2 - Data C o l l e c t i o n 1. M a i l d i e t - r e c o r d forms at a p p r o p r i a t e time 2. I n t e r v i e w s u b j e c t s 3. Compile cro s s - c h e c k form of the s u b j e c t ' s name and survey number Stage 3 - Data A n a l y s i s and I n t e r p r e t a t i o n 1. Code o b t a i n e d i n f o r m a t i o n and check c o d i n g 2. Key-punching 3. Data a n a l y s i s by computer 4. F i n a l r e p o r t May 1 -Oct. 16, 1975 Nov. Dec . Dec . -Jan. Feb. 1975 1975 1976 1976 Data A n a l y s i s Data c o l l e c t e d were coded, key punched on c a r d s , and t r e a t e d s t a t i s t i c a l l y by computer a n a l y s i s . 58 Comparison of data c o l l e c t e d by the two d i e t a r y data c o l l e c t i o n methods used i n the study was conducted by t - t e s t f o r s i g n i f i c a n t d i f f e r e n c e s i n the group means. The r e l a t i o n s h i p between the i n d i v i d u a l c r i t e r i o n v a r i a b l e s was i n v e s t i g a t e d by c o r r e l a t i o n a n a l y s i s u s i n g the Pearson product moment c o r r e l a t i o n c o e f f i c i -e n t. The same method of a n a l y s i s was used to determine the r e l a t i o n s h i p between the i n d i v i d u a l v a r i a t e s . A n a l y s i s of the t - d i s t r i b u t i o n was used to study the r e l a t i o n s h i p of the v a r i a t e s (other than the c a l o r i c i n t a k e ) to the presence o f h y p e r l i p o p r o t e i n e m i a (hypotheses 1,2,3,5,6,7,8,9). The c o r r e l a t i o n between c a l o r i c i n t a k e and the presence of h y p e r l i p o p r o t e i n e m i a ( h y p o t h e s i s 4) was i n v e s t i g a t e d w i t h the use of the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t . The r e l a t i o n s h i p of the v a r i a t e s to the i n d i v i d u a l c r i t e r i o n v a r i a b l e s (serum t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n ) was determined by c o r r e l a t i o n a n a l y s i s . The Pearson product moment c o r r e l a t i o n c o e f f i c i e n t was employed to determine the c o r r e l a t i o n between smoking, c e s s a t i o n of smoking or non-smoking and the i n d i v i d u a l c r i t e r i o n v a r i a b l e s . A n a l y s i s o f v a r i a n c e was conducted t o observe i f any d i f f e r e n c e e x i s t e d between smokers, ex-smokers and non-smokers and t h e i r serum t r i g l y c e r i d e c o n c e n t r a t i o n . 59 The c o r r e l a t i o n between s e l e c t e d combinations of v a r i a t e s and the presence of h y p e r l i p o p r o t e i n e m i a ( o b j e c t i v e 10) was i n v e s t i g a t e d by m u l t i v a r i a t e c a n o n i c a l c o r r e l a t i o n a n a l y s i s . M u l t i p l e r e g r e s s i o n a n a l y s i s was employed to determine the r e l a t i o n s h i p of s e l e c t e d combinations of v a r i a t e s to the i n d i v i d u a l c r i t e r i o n v a r i a b l e s . CHAPTER IV FINDINGS AND INTERPRETATIONS In t h i s study of men aged t h i r t y to s i x t y y e ars who were admitted to S t . P a u l ' s H o s p i t a l f o r c a r d i a c c a t h e t e r -i z a t i o n , the nature of the r e l a t i o n s h i p s between the c r i t e r i o n v a r i a b l e s ( f a s t i n g serum t r i g y l c e r i d e and f a s t i n g serum c h o l e s t e r o l ) and the v a r i a t e s ( n u t r i t i o n a l p r a c t i c e s , demographic f a c t o r s and anthropometry) were e x p l o r e d . The i n t e r r e l a t i o n s h i p s among the v a r i a t e s themselves were a l s o i n v e s t i g a t e d . Ninety-one s u b j e c t s were i n v o l v e d i n the study. However twenty-seven s u b j e c t s had to be e l i m i n a t e d l e a v i n g a t o t a l of s i x t y - f o u r p a r t i c i p a n t s . The reasons f o r the e l i m i n a t i o n of the s u b j e c t s were: a. c u r r e n t l y on a n t i a t h e r o g e n i c treatment 15 b. c u r r e n t l y t a k i n g h y p o l i p i d e m i c drugs 4 c. diagnosed as d i a b e t i c 4 d. d i e t a r y data not a v a i l a b l e 4 A summary of the data o b t a i n e d from the study i s out-l i n e d i n T a b l e I I . C r i t e r i o n V a r i a b l e s T r i g l y c e r i d e s The f a s t i n g serum t r i g l y c e r i d e l e v e l s showed a wide range (Table I I I ) . Of the s i x t y - f o u r s u b j e c t s i n c l u d e d i n 60 61 TABLE I I MEAN AND STANDARD DEVIATION FOR VARIABLES OBSERVED IN THE STUDY V a r i a b l e Mean Standard D e v i a t i o n Carbohydrate (gm.) 210 .1562 + 90.9762 Fat (gm.) 118 .3906 + 55.8492 P o l y u n s a t u r a t e d f a t t y a c i d (gm.) 8 .8750 + 5.2144 Sa t u r a t e d f a t t y a c i d (gm. ) 43 .5781 + 23.2889 C a l o r i e s 2374 .2812 + 882.7813 A l c o h o l (gm.) 14 .9844 + 25.7882 Height (cm.) 171 .8625 + 8.6811 Weight (kg.) 76 .3328 + 12.4134 Arm c i r c u m f e r e n c e (c.m.) 31 .3578 + 2.9516 Age (years) 49 .7188 + 7.4332 T r i g l y c e r i d e s (mg./100ml. ) 184 .5781 + 84.1212 C h o l e s t e r o l (mg./lOOml.) 208 .2031 + 28.9341 Bloo d Glucose (mg./lOOml. ) 103 .4062 + 10 .9599 S t a r c h (gm.) 101 .5156 + 50.4500 Sucrose (gm.) 59 .1563 + 48.3867 Converted s k i n f o l d 196 .8874 + 19.8468 Pon d e r a l index 12 .3104 + 0.6337 Percent sucrose 26 .4353 + 16.5223 Percent f a t 43 .8233 + 9.7232 P:S r a t i o 0 .2866 + 0.2986 Percent s t a r c h 48 .9476 + 19.0905 Percent a l c o h o l 4 .1830 + 7.3010 62 the survey o n l y twenty-three e x h i b i t e d l e v e l s w i t h the range accepted as normal by St. P a u l ' s H o s p i t a l l a b o r a t o r y i . e . 35-135 mg./lOO ml. serum. T h i s would appear to support the view of Levy, Bonnel and E r n s t (1971) that both c h o l e s t e r o l and t r i g l y c e r i d e c o n c e n t r a t i o n must be measured when e v a l u -a t i n g h y p e r l i p o p r o t e i n e m i a . TABLE I I I FASTING SERUM TRIGLYCERIDE LEVELS OF PARTICIPANTS Measure Serum t r i g l y c e r i d e (mg./100ml.) Mean and S.D.'3 Range + a 184.58 - 84.12 59.00 - 552.00 a The mean f a s t i n g serum t r i g l y c e r i d e l e v e l exceeds the upper l i m i t o f the normal range. b Standard d e v i a t i o n 63 C h o l e s t e r o l T able IV shows the range of the f a s t i n g serum c h o l e s -t e r o l l e v e l s t o be,much l e s s than t h a t of the f a s t i n g serum t r i g l y c e r i d e c o n c e n t r a t i o n . TABLE IV FASTING SERUM CHOLESTEROL LEVELS OF PARTICIPANTS Measure Serum c h o l e s t e r o l (mg./100ml.) Mean and S.D. Range 208.20 t 28.93 143.00 - 275.00 Only two of the s i x t y - f o u r s u b j e c t s produced f a s t i n g serum c h o l e s t e r o l l e v e l s g r e a t e r than the range accepted as normal by S t . P a u l ' s H o s p i t a l l a b o r a t o r y i . e . 150-260 mg./100ml.serum. One of these s u b j e c t s e x h i b i t e d a serum t r i g l y c e r i d e l e v e l o f 162 mg./100ml. w h i l e the o t h e r s u b j e c t had a f a s t i n g serum t r i g l y c e r i d e l e v e l of 552 mg./100ml., i l l u s t r a t i n g the importance of measuring both c h o l e s t e r o l and t r i g l y c e r i d e s i n o r d e r t o e v a l u a t e the type of hyper-l i p o p r o t e i n e m i a present ( F r e d r i c k s o n , 1973). I t i s i n t e r e s t i n g to note the almost normal l e v e l s of serum c h o l e s t e r o l demonstrated by the s u b j e c t s . A c c o r d i n g to Lewis et a l . (1974) serum c h o l e s t e r o l c o n c e n t r a t i o n s 64 have been found to i n c r e a s e w i t h age. A l s o a r e l a t i o n s h i p has been demonstrated between o b e s i t y and plasma l i p i d s ( O l e f s k y , Reaven and Farquaker, 1974a; H a l l , et a l . 1972; L i s c k , et al. 1974; Ashley and Kannel, 1974; Bagdade et a l . 1971). The anthropometric r e s u l t s of t h i s study show that 67% of the s u b j e c t s s u f f e r e d from overweight. T h e r e f o r e , c o n s i d e r i n g these two r i s k f a c t o r s a l o n e , a g r e a t e r number of abnormally h i g h l e v e l s o f serum c h o l e s t e r o l would have been expected i n t h i s s u rvey. Although an attempt was made to prevent b i a s , the f a c t t h a t these s u b j e c t s were p a t i e n t s admitted t o h o s p i t a l f o r c a r d i a c c a t h e t e r i z a t i o n must be c o n s i d e r e d . Weight reduc-t i o n , d i e t a r y m o d i f i c a t i o n s , i n c r e a s e d e x e r c i s e , and c e s s a -t i o n of smoking c o u l d have been i n s t i t u t e d by the s u b j e c t as soon as an i n d i c a t i o n o f a c a r d i a c problem was made known to him. T h i s p a r t i c u l a r f a c t o r was i n v e s t i g a t e d d u r i n g the i n t e r v i e w but c o u l d not be c o n t r o l l e d e n t i r e l y . V a r i a t e s N u t r i t i o n a l P r a c t i c e s A l l o f the n u t r i t i o n a l measurements were r e c o r d e d on a continuous s c a l e . T o t a l carbohydrate The t o t a l carbohydrate consumption of the p a r t i c i p a n t s v a r i e d c o n s i d e r a b l y (Table V ) . 65 TABLE V CARBOHYDRATE CONSUMPTION OF PARTICIPANTS Measure Carbohydrate (gms.) Carbohydrate C a l o r i e s Mean and S.D. Range 210.16 ± 90.98 89.00 - 546.00 840.62 t 363.9 356.00 - 2184.00 Sucrose and s t a r c h I t s h o u l d be noted t h a t the f i g u r e s o b t a i n e d f o r both sucrose and s t a r c h consumption must be c o n s i d e r e d o n l y as an e s t i m a t i o n due to the d i f f i c u l t y i n s e c u r i n g r e l i a b l e c o m p o s i t i o n t a b l e s . However, as a r e s u l t of the r e s e a r c h which has been conducted t o i n v e s t i g a t e the r e l a t i o n s h i p of sucrose and s t a r c h t o the presence of h y p e r l i p o p r o t e i n e m i a (Kaufmann and K a p i t u l n i k , 1972; N i k k i l a and K e k k i , 1973; Bolzana et a l . , 1972), i t i s of i n t e r e s t to i n v e s t i g a t e the es t i m a t e d i n t a k e of sucrose and s t a r c h o b t a i n e d from t h i s s tudy. T a b l e VI shows the d i s t r i b u t i o n o f the consumption of sucrose by the p a r t i c i p a n t s i n t h i s study. 66 TABLE VI SUCROSE CONSUMPTION OF PARTICIPANTS Measure Sucrose (gm.) Percent Sucrose Mean and S.D. Range 59.16 i 48.39 0.00 - 201.00 26.44 t 16.52 0.00 - 69.36 Sucrose as percent t o t a l carbohydrate consumed. I t has been recommended by the Committee on N u t r i t i o n of the American Heart A s s o c i a t i o n (1974) t h a t a dependence on foods c o n t a i n i n g complex n a t u r a l carbohydrate i s p r e f e r a b l e to e x c e s s i v e use of r e f i n e d sugar. T a b l e VII i l l u s t r a t e s t h a t the consumption of s t a r c h was extremely v a r i e d . TABLE VII STARCH CONSUMPTION OF PARTICIPANTS Measure St a r c h (gm.) Percent S t a r c h a Mean and S.D1.' Range 101.52 t 50.45 0.00 - 317.00 48.95 t 19.09 0.00 - 95.16 Starch as percent t o t a l carbohydrate consumed. 67 Fat T a b l e s V I I I and IX show the f a t and f a t t y a c i d consump-t i o n , r e s p e c t i v e l y . TABLE V I I I FAT CONSUMPTION OF PARTICIPANTS Measure Fat (gm.) Fat C a l o r i e s Percent Fat a Mean and S.D. Range 118.39 t 55.85 20.00 - 272.00 1065.51 t 502.64 180.00 - 24i48.00 43.82 - 9.72 18.97 - 67.12 Fat as percent t o t a l c a l o r i e s consumed. It i s of i n t e r e s t t o note that the mean percent t o t a l c a l o r i e s from f a t i s 43.82. Sherwin (1974) and Kannel (1971) recommended t h a t the f a t content of a d i e t s h o u l d be 30% or l e s s o f the t o t a l c a l o r i e s w h i l e the Committee on N u t r i t i o n of the American Heart A s s o c i a t i o n (1974) recommended that the t o t a l c a l o r i e s from f a t s h o u l d be no more than 35%. Only t h r e e of the s i x t y - f o u r s u b j e c t s consumed d i e t s w i t h a P:S r a t i o g r e a t e r than o r equal t o one. Kannel (1971) proposed t h a t the P:S r a t i o s h o u l d be 2:1 and H u l l e y (1972) suggested t h a t d i e t s of a h i g h P:S r a t i o lower serum c h o l e s -t e r o l . A mean P:S r a t i o of 0.287 i s extremely low p a r t i c u l a r l y 68 when h i g h e r r a t i o s are recommended. A c c o r d i n g to F r e d r i c k s o n (1971) the average American d i e t c o n t a i n s a P:S r a t i o of 0.3 showing that t h i s group of s u b j e c t s demonstrated a mean P:S r a t i o near the American average. TABLE IX FATTY ACID CONSUMPTION OF PARTICIPANTS Measure P.U.F.A. (gm.) * Sat. F.A.. (gm.) b P:S R a t i o Mean and S.D. Range 8.88 i 5.21 0.00 - 23.00 43.58 - 23.29 5.00 - 102.00 0.29 - 0.30 0.00 - 1.67 P o l y u n s a t u r a t e d f a t t y a c i d . S a t u r a t e d f a t t y a c i d . T o t a l c a l o r i e s The c a l o r i c i n t a k e data o b t a i n e d d u r i n g the study are pr e s e n t e d i n Table X. TABLE X CALORIC CONSUMPTION OF PARTICIPANTS Measure C a l o r i e s Mean and S.D. Range 2374.28 t 882.78 922.00 - 5408.00 69 As can be seen from the above t a b l e the c a l o r i c i n t a k e v a r i e d c o n s i d e r a b l y . The energy requirement o f an i n d i v i d u a l i s extremely d i f f i c u l t to p r e d i c t due to the l a r g e number of v a r i a b l e s a f f e c t i n g such a requirement e.g., age, h e i g h t and p h y s i c a l a c t i v i t y . The recommended i n t a k e s of energy f o r a d u l t s i n the Canadian D i e t a r y Standards (1975) are pr e s e n t e d as i n f l u e n c e d by age and a c t i v i t y . A l c o h o l i n t a k e Table XI d i s p l a y s the wide v a r i a t i o n observed i n the a l c o h o l consumption of the s u b j e c t s . TABLE XI ALCOHOL CONSUMPTION OF PARTICIPANTS Measure A l c o h o l (gm.) A l c o h o l C a l o r i e s Percent A l c o h o l Mean and S.D. Range 14.98 - 25.79 0.00 - 108.00 103.84 - 178.71 0.00 - 748.44 4.18 - 7.30 0.00 - 31.66 A l c o h o l as percent t o t a l c a l o r i e s consumed. As can be seen from the t a b l e above, the a l c o h o l i n t a k e ranges from 0-108 grams a day. Thus, 64% of the p a r t i c i p a n t s consumed no a l c o h o l at a l l g i v i n g an extremely unusual d i s t r i -b u t i o n of a l c o h o l consumption. 70 Type of n u t r i t i o n a l data c o l l e c t i o n Two methods were used t o r e c o r d the d i e t a r y i n t a k e of the s u b j e c t s i . e . the three-day food r e c o r d or twenty-four hour r e c a l l method (Table X I I ) . TABLE XII DISTRIBUTION OF THE DIETARY DATA COLLECTION METHODS USED Method Number o f S u b j e c t s Twenty-four hour r e c a l l Three-day food r e c o r d TOTAL 42 22 64 T - d i s t r i b u t i o n a n a l y s i s was conducted to i n v e s t i g a t e the p o s s i b i l i t y of i n c o n s i s t e n c i e s between the data o b t a i n e d by the twenty-four hour r e c a l l and that o b t a i n e d from the three-day f o o d r e c o r d . The food r e c o r d e d on the f i n a l day of the three-day food r e c p r d was used f o r data a n a l y s i s . A l l o f the d i e t a r y v a r i a t e s were s t u d i e d and no s i g n i f i c a n t v a r i a t i o n was observed at the 0.05 l e v e l o f s i g n i f i c a n c e between the data c o l l e c t e d by the three-day food r e c o r d and th a t o b t a i n e d from the twenty-four hour r e c a l l . Demographic F a c t o r s Smoking Smoking has been suggested as a r i s k f a c t o r i n the 71 presence of h y p e r l i p o p r o t e i n e m i a (Kannel, 1971; Sherwin, 1974). Only t h r e e of the s u b j e c t s i n v o l v e d i n the prese n t study smoked a pipe w h i l e not one s u b j e c t smoked a c i g a r . Informa-t i o n r e g a r d i n g c i g a r e t t e smoking i s i n c l u d e d i n T a b l e X I I I . TABLE X I I I DISTRIBUTION OF PARTICIPANTS BY CIGARETTE SMOKING HABITS Average number of c i g a r e t t e s / d a y Absolute frequency o.o a 15 1.0b 27 2.0 1 6.0 1 10.0 2 12.0 1 15.0 3 20.0 9 30.0 1 40.0 1 50.0 3 TOTAL 64 non-smoker ex-smoker 72 As can be seen from the t a b l e above, 15 of the s u b j e c t s were non-smokers while 27 (42%) were ex-smokers. Only 34% of the s u b j e c t s were smoking at the time of the study. P h y s i c a l a c t i v i t y P h y s i c a l a c t i v i t y was s c o r e d a c c o r d i n g t o the system o u t l i n e d p r e v i o u s l y (p.54). Table XIV p r e s e n t s the frequency d i s t r i b u t i o n o f p h y s i c a l a c t i v i t y u s i n g t h i s s c o r i n g system. TABLE XIV DISTRIBUTION OF PARTICIPANTS BY PHYSICAL ACTIVITY SCORE Code Absolute frequency 1.0 13 2.0 18 3.0 29 4.0 4 T o t a l 64 T h e r e f o r e , 23% of the p a r t i c i p a n t s were c l a s s e d as seden t a r y and 28% as low moderately a c t i v e . It has been suggested by Kannel (1971) that sedentary men are more sus-c e p t i b l e to coronary a t t a c k s than p h y s i c a l l y a c t i v e men. Thus i t i s of i n t e r e s t to note the l a r g e percentage of par-t i c i p a n t s (51%) who were not i n d u l g i n g i n high moderately a c t i v e or v i g o r o u s a c t i v i t y . 73 Family h i s t o r y of heart d i s e a s e It has been suggested (Glueck et a l . , 1974; G o l d s t e i n et a l . , 1973; F r e d r i c k s o n et a l . , 1973) that h y p e r l i p o -p r o t e i n e m i a may be' f a m i l i a l . Of the s i x t y - f o u r p a r t i c i p a n t s i n the study, twenty-one r e p o r t e d to have no f a m i l y h i s t o r y of heart d i s e a s e while f o r t y - t h r e e r e p o r t e d t h a t a parent and/or s i b l i n g had been diagnosed as s u f f e r i n g from some type of heart d i s e a s e . Age Table XV o u t l i n e s the measures of c e n t r a l tendency and d i s p e r s i o n f o r age among the p a r t i c i p a n t s of the study. TABLE XV DISTRIBUTION OF PARTICIPANTS BY AGE Measure Age (years) Mean and S.D. Range 49.72 - 7.43 34.00 - 60.00 The l e v e l s of serum c h o l e s t e r o l and t r i g l y c e r i d e con-c e n t r a t i o n have been found to i n c r e a s e w i t h age (Lewis et a l . , 1974; Levy, 1973; F r e d r i c k s o n , Levy and Lees, 1967). Lewis et a l . (1974) found i n t h e i r study that the h i g h e s t c o n c e n t r a t i o n of serum t r i g l y c e r i d e s and c h o l e s t e r o l was seen i n the 50-59 year age-group. F i f t y - s i x percent of the 74 p a r t i c i p a n t s were shown to f a l l w i t h i n t h i s group. Glucose i n t o l e r a n c e The measures of d i s p e r s i o n and c e n t r a l tendency show-i n g the f a s t i n g blood glucose of the p a r t i c i p a n t s i s i n d i c a t e d i n Table XVI. TABLE XVI FASTING BLOOD GLUCOSE LEVELS OF PARTICIPANTS Measure F a s t i n g Blood Glucose (mg./100ml.) Mean and S.D. Range 103.41 - 10.96 76.00 - 140.00 The range of f a s t i n g b l o o d glucose c o n s i d e r e d normal by St. P a u l ' s H o s p i t a l l a b o r a t o r y i s 65 - HOmg./100ml. An abnormally high f a s t i n g b l o o d glucose l e v e l was found among 18.7% of the p a r t i c i p a n t s . Anthropometry Table XVII shows the data o b t a i n e d on h e i g h t , weight and ponderal index. 75 TABLE XVII HEIGHT, WEIGHT AND PONDERAL INDEX OF PARTICIPANTS Measure Height (c .m.) Weight (kg.) Ponderal Index Mean and S.D. Range 171.87 - 8.69 148.50 - 190.50 76.33 - 12.41 43.70 - 113.60 12.31 t 0.63 10.94 - 14.33 Ac c o r d i n g to N u t r i t i o n Canada (1973), 12.5 i s the s t a n -dard p o n d e r a l index w h i l e a ponde r a l index of 11.6 i n d i c a t e s o b e s i t y . In t h i s study, 12.5% of the s u b j e c t s e x h i b i t e d a pon d e r a l index l e s s than 11.6 wh i l e a t o t a l of 67% of the s u b j e c t s p r e s e n t e d w i t h a po n d e r a l index below the s t a n d a r d . T h e r e f o r e , 67% of the p a r t i c i p a n t s i n the study may be c l a s s i -f i e d as overweight. The t r i c e p s k i n f o l d t h i c k n e s s and arm-circumference measurement s c o r e s are pr e s e n t e d i n Table X V I I I . 76 TABLE XVIII ARM CIRCUMFERENCE AND TRICEP SKINFOLD THICKNESS OF PARTICIPANTS Measure Arm Circumference (c.m.) S k i n f o l d (m.m. ) S k i n f o l d a conversion Mean and S.D. Range 31.36 t 2.95 23.00 - 38.00 i 11.98 t 4.00 4.10 - 23.40 196.89 - 19.85 136.17 - 233.45 A c c o r d i n g to Edwards et a l . (1955): Because the v a l u e s o b t a i n e d w i t h the s k i n f o l d c a l i p e r g i v e a markedly non-normal frequency d i s t r i b u t i o n i t i t n ecessary f o r most purposes to t r a n s f o r m them i n t o a l o g s c a l e b e f o r e use (p.133). The t r a n s f o r m a t i o n used f o r t h i s purpose i s : 100 l o g 10 ( r e a d i n g i n 0.1 m.m - 18) J e l l i f f e (1966) s t a t e d that the s t a n d a r d t r i c e p s k i n -f o l d t h i c k n e s s of the a d u l t male i s 12.5 m.m.whereas the s t a n d a r d arm c i r c u m f e r e n c e i s 29.3 c m . In the present study, 43.7% of the s u b j e c t s e x h i b i t e d a s k i n f o l d t h i c k n e s s g r e a t e r than 12.5 m.m. i n d i c a t i n g excess energy s t o r e s . An arm c i r c u m f e r e n c e of l e s s than the s t a n d a r d (showing low muscle r e s e r v e s ) e x i s t e d i n 25% of the s u b j e c t s . R e l a t i o n s h i p Between the C r i t e r i o n V a r i a b l e s The r e l a t i o n s h i p between the c r i t e r i o n v a r i a b l e s was i n v e s t i g a t e d u s i n g the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t . The serum t r i g l y c e r i d e c o n c e n t r a t i o n and the 77 serum c h o l e s t e r o l c o n c e n t r a t i o n were found to be p o s i t i v e l y c o r r e l a t e d (Table XIX). TABLE XIX PEARSON PRODUCT MOMENT CORRELATION COEFFICIENT OF THE CRITERION VARIABLES V a r i a b l e s C o e f f i c i e n t Cases L e v e l of s i g n i f i c a n c e Serum t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n 0.3796 64 0.002 Although o n l y two of the s u b j e c t s e x h i b i t e d abnormally h i g h l e v e l s of serum c h o l e s t e r o l , 67% of the p a r t i c i p a n t s had serum c h o l e s t e r o l c o n c e n t r a t i o n s w i t h i n the upper 25% of the normal range. The c o n c e n t r a t i o n of a l l l i p i d s and l i p o -p r o t e i n s tend to i n c r e a s e w i t h age (Levy, 1973). T h e r e f o r e w i t h an age range of 30-60 years and with 56% of the respon-dents being 50-59 years of age, one would expect the l e v e l s of both l i p i d s to be at the upper l i m i t or h i g h e r than normal. R e l a t i o n s h i p s Among the V a r i a t e s The Pearson product moment c o r r e l a t i o n c o e f f i c i e n t was used to determine the r e l a t i o n s h i p s between the v a r i a t e s used i n the study. T a b l e XX shows some of the c o r r e l a t i o n c o e f f i c i e n t s o b t a i n e d by t h i s a n a l y s i s . From the t a b l e i t i s p o s s i b l e to see that some i n t e r -78 r e l a t i o n s h i p does e x i s t between the v a r i a t e s but that t h i s r e l a t i o n s h i p i s l i m i t e d . E x e r c i s e and C a l o r i c Intake No r e l a t i o n s h i p was observed between e x e r c i s e and c a l o r i e s . T h i s f i n d i n g was s i m i l a r to that of the N u t r i t i o n Canada Survey (1973) . TABLE XX PEARSON PRODUCT MOMENT CORRELATION COEFFICIENTS OF SELECTED VARIATES V a r i a b l e s C o e f f i c i e n t Cases L e v e l of s i g n i f i c a n c e E x e r c i s e and C a l o r i e s 0.1824 64 0.149 E x e r c i s e and S k i n f o l d -0.3746 64 0.002 a E x e r c i s e and Ponderal Index 0.2336 64 0.063 Blood glucose and Ponderal Index -0.1843 64 0.145 Blood glucose and C a l o r i e s CHO 0.2017 64 0.110 C a l o r i e s and Age -0.1974 64 0.118 S i g n i f i c a n t at the 5% l e v e l o f s i g n i f i c a n c e . D i e t a r y c a l o r i e s d e r i v e d from carbohydrate. 79 E x e r c i s e and Ponderal Index The n o n - s i g n i f i c a n t r e l a t i o n s h i p between e x e r c i s e and p o n d e r a l index at the 0.05 l e v e l of s i g n i f i c a n c e i s of i n t e r e s t as both e x e r c i s e and ponderal index were shown to be r e l a t e d to the c r i t e r i o n v a r i a b l e s by the t - t e s t . A c o r r e l a t i o n between e i t h e r e x e r c i s e or c a l o r i e s and p o n d e r a l index would have been expected. The s m a l l sample s i z e of the study may have a f f e c t e d the r e s u l t s as the l e v e l of s i g -n i f i c a n c e f o r the c o r r e l a t i o n between e x e r c i s e and p o n d e r a l index was 0.063. The N u t r i t i o n Canada r e s u l t s (1973) suggested t h a t c a l o r i e s alone do not account f o r the overweight problem. In the r e p o r t of the N u t r i t i o n Canada n a t i o n a l survey i t was proposed t h a t both f a c t o r s , c a l o r i c i n t a k e and p h y s i c a l a c t i v i t y , need to be c o n s i d e r e d when d e a l i n g w i t h the prob-lem of overweight. E x e r c i s e and T r i c e p S k i n f o l d T h i c k n e s s A n e g a t i v e r e l a t i o n s h i p between e x e r c i s e and the t r i c e p s k i n f o l d t h i c k n e s s was observed at the 0.002 l e v e l of s i g -n i f i c a n c e . T h i s r e l a t i o n s h i p supports the suggested r e l a t i o n -s h i p between pond e r a l index and e x e r c i s e and i m p l i e s that p h y s i c a l a c t i v i t y a f f e c t s the development of subcutaneous f a t . B lood Glucose and Ponderal Index The e f f e c t of c e r t a i n parameters on the f a s t i n g b l o o d glucose l e v e l i s i n t e r e s t i n g as i t has been suggested that 80 abnormal glucose t o l e r a n c e may be a s s o c i a t e d w i t h the presence of h y p e r l i p o p r o t e i n e m i a ( S c h o n f i e l d et a l . , 1974; F r e d r i c k s o n , Levy and Lees, 1967). O l e f s k y , Reaven and Farquakar (1974b) suggested that o b e s i t y i s r e l a t e d to hyperglycemia which i n t u r n i s a s s o c i a t e d w i t h h y p e r l i p o p r o t e i n e m i a . The non-s i g n i f i c a n t (at the 0.05 l e v e l ) r e l a t i o n s h i p e x i s t i n g i n t h i s study between pond e r a l index and bloo d g l u c o s e does not support the view that o b e s i t y i s a s s o c i a t e d w i t h hyperglycemia. D i e t a r y Carbohydrate and Blood Glucose No a s s o c i a t i o n between a hig h carbohydrate d i e t and blo o d glucose l e v e l was observed u s i n g the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t . The r e l a t i o n s h i p of bloo d g l u c o s e t o h y p e r l i p o p r o t e i n e m i a w i l l be d i s c u s s e d i n the f o l l o w i n g s e c t i o n . C a l o r i c Intake and Age No c o r r e l a t i o n was observed between c a l o r i c i n t a k e and age by Pearson product moment c o r r e l a t i o n c o e f f i c i e n t a n a l y s i s . No e x p l a n a t i o n , o t h e r than p o p u l a t i o n s i z e , can be p r o v i d e d f o r t h i s o b s e r v a t i o n . R e l a t i o n s h i p s Between the C r i t e r i o n V a r i a b l e s and the V a r i a t e s The serum l e v e l s of t r i g l y c e r i d e s and c h o l e s t e r o l were s u b j e c t e d to a nominal measurement which was dichotomized (Table X XI). 81 TABLE XXI SERUM TRIGLYCERIDE AND CHOLESTEROL CONCENTRATIONS REPORTED AS A DICHOTOMOUS VARIABLE Group L i p i d Number 1 High t r i g l y c e r i d e c h o l e s t e r o l 41 2 Normal t r i g l y c e r i d e and c h o l e s t e r o l 23 T o t a l 64 The normal serum ranges of c h o l e s t e r o l and t r i g l y c e r i d e c o n c e n t r a t i o n s used were those observed by St. P a u l ' s H o s p i t a l l a b o r a t o r y i . e . t r i g l y c e r i d e s 35-135 mg./100ml. and c h o l e s t e r o l 150-260 mg./100ml. The r e l a t i o n s h i p between the v a r i a t e s and the presence of h y p e r l i p o p r o t e i n e m i a was i n v e s t i g a t e d u s i n g these groups. In a d d i t i o n t r i g l y c e r i d e and c h o l e s t e r o l con-c e n t r a t i o n s were c o n s i d e r e d i n d i v i d u a l l y . The r e l a t i o n s h i p between the v a r i a t e s and t r i g l y c e r i d e c o n c e n t r a t i o n as w e l l as between the v a r i a t e s and c h o l e s t e r o l c o n c e n t r a t i o n was e x p l o r e d . The frequency d i s t r i b u t i o n of the t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n s of the respondents i s shown i n Table XXII. 82 TABLE XXII DISTRIBUTION OF PARTICIPANTS BY TRIGLYCERIDE AND CHOLESTEROL CONCENTRATIONS Category Absolute Frequency Normal t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n 23 E l e v a t e d t r i g l y c e r i d e ; normal c h o l e s t e r o l 39 E l e v a t e d t r i g l y c e r i d e and c h o l e s t e r o l 2 T o t a l 64 It i s o f i n t e r e s t to note that o n l y two of the s u b j e c t s showing abnormally h i g h t r i g l y c e r i d e c o n c e n t r a t i o n s a l s o e x h i b i t e d a h i g h c h o l e s t e r o l c o n c e n t r a t i o n . A n a l y s i s of R e l a t i o n s h i p of S e l e c t e d V a r i a t e s to the Presence of H y p e r l i p o p r o t e i n e m i a The r e l a t i o n s h i p o f s e l e c t e d v a r i a t e s t o the presence of h y p e r l i p o p r o t e i n e m i a was i n v e s t i g a t e d by the t - t e s t o r by the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t . The c r i t e r i o n v a r i a b l e s were grouped a c c o r d i n g to the format shown i n Table XXI. The r e s u l t s of t - t e s t a n a l y s i s are r e p o r t e d i n Table X X I I I . 83 TABLE XXIII T-DISTRIBUTION OF THE RELATIONSHIP OF SELECTED VARIATES TO THE PRESENCE OF HYPERLIPOPROTEINEMIA V a r i a t e T-Value S i g n i f i c a n c e P 0.05 Percent sucrose 0.65 N.S. a Percent f a t -1.68 N.S. P:S r a t i o -0.59 N.S. Percent s t a r c h -0.34 N.S. Ponderal index -2.95 s. b Percent a l c o h o l 0 .76 N.S. E x e r c i s e - 2.25 s. C i g a r e t t e smoking -0.16 N.S. Converted s k i n f o l d 2.58 s. Age 1.32 N.S. n o n - s i g n i f i c a n t " s i g n i f i c a n t A n e g a t i v e c o r r e l a t i o n was shown t o e x i s t between the ponderal index and the presence of h y p e r l i p o p r o t e i n e m i a (as d e f i n e d by abnormally high t r i g l y c e r i d e and/or c h o l e s t e r o l c o n c e n t r a t i o n s ) and between e x e r c i s e and presence of hyper-l i p o p r o t e i n e m i a . The r e l a t i o n s h i p between s k i n f o l d t h i c k n e s s (transformed to the l o g s c a l e ) and the presence of h y p e r l i p o -84 p r o t e i n e m i a was shown to be p o s i t i v e . A l l of these r e l a t i o n -s h i p s e x i s t e d at the 0.05 l e v e l of s i g n i f i c a n c e f o r the two-t a i l e d t e s t . The o t h e r v a r i a t e s examined by t h i s method of a n a l y s i s i . e . sucrose as percent t o t a l carbohydrate, f a t as percent t o t a l c a l o r i e s , P:S r a t i o , s t a r c h as percent t o t a l carbo-hydrate, a l c o h o l as percent t o t a l c a l o r i e s and c i g a r e t t e smoking were shown to have no s i g n i f i c a n t r e l a t i o n s h i p t o the presence o f h y p e r l i p o p r o t e i n e m i a . Ponderal index Ashley and Kannel (1974) suggested that o r d i n a r y o b e s i t y encountered i n the g e n e r a l p o p u l a t i o n i s a s s o c i a t e d w i t h an i n c r e a s e d i n c i d e n c e of h y p e r l i p o p r o t e i n e m i a . The n e g a t i v e c o r r e l a t i o n shown to e x i s t between the ponderal index and the presence of h y p e r l i p o p r o t e i n e m i a i n t h i s study supports t h i s statement. L i s c k et a l . (1974) found from t h e i r s t u d i e s t h a t weight r e d u c t i o n c o u l d be a s s o c i a t e d w i t h a r e d u c t i o n i n the plasma t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n s i n some p a t i e n t s w i t h h y p e r l i p o p r o t e i n e m i a . U n f o r t u n a t e l y , due to the o r g a n i -z a t i o n of the study, long-term f o l l o w - u p of the s u b j e c t s c o u l d not be undertaken. The f i n d i n g s of t h i s study t h e r e -f o r e support h y p o t h e s i s 6. 85 S k i n f o l d t h i c k n e s s T h i s anthropometric measurement p r o v i d e s an i n d i c a -t i o n of the energy s t o r e s o f the s u b j e c t s t u d i e d . The p o s i t i v e r e l a t i o n s h i p between t r i c e p s k i n f o l d t h i c k n e s s and the presence of h y p e r l i p o p r o t e i n e m i a found i n t h i s study supports the r e l a t i o n s h i p found between pond e r a l index and the presence o f h y p e r l i p o p r o t e i n e m i a . Together these measurements support the view t h a t a r e l a t i o n s h i p e x i s t s between o b e s i t y and plasma l i p i d s ( O l e f s k y , Reaven and Farquahar, 1974a,b; H a l l e_t ajL. , 1972; L i s c k et a l . , 1974; Ashley and Kannel 1974). E x e r c i s e The extent of p h y s i c a l a c t i v i t y normally conducted by the respondent was sc o r e d w i t h i n a range o f one to f o u r i . e . sedentary to v i g o r o u s . Among the p a r t i c i p a n t s of t h i s study, l a c k of p h y s i c a l a c t i v i t y appeared t o be c l o s e l y a s s o c i a t e d w i t h an abnormally high t r i g l y c e r i d e and/or c h o l e s t e r o l c o n c e n t r a t i o n . T h i s f i n d i n g s u p p o r t s the s u g g e s t i o n of Kannel, S o r l i e and McNamara (1971) that p h y s i c a l a c t i v i t y c o n t r i b u t e s to coronary r i s k . Hypothesis 8 i s accepted. Sucrose as percent t o t a l carbohydrate No r e l a t i o n s h i p was found t o e x i s t between t h i s v a r i a t e and the presence o f h y p e r l i p o p r o t e i n e m i a . T h i s f i n d i n g t h e r e f o r e r e j e c t s h y p o t h e s i s 1. 86 S e v e r a l r e s e a r c h e r s have suggested that the s u b s t i t u -t i o n of sucrose f o r s t a r c h i n the d i e t causes an i n c r e a s e i n the serum t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s (Kaufmann and K a p i t u l n i k , 1972; N i k k i l a and Ke k k i , 1973; Bolzana et a l . , 1972). The reason f o r the c o n f l i c t i n g f i n d i n g of t h i s study c o u l d be due to the f a c t that the data r e l a t i n g to sucrose consumption can onl y be regarded as an e s t i m a t e . M u l t i v a r i a t e a n a l y s i s u s i n g s e v e r a l combinations of the d i e t a r y f a c t o r s may r e v e a l s t r o n g e r r e l a t i o n s h i p s between s e l e c t e d d i e t a r y v a r i a t e s and the c r i t e r i o n v a r i a b l e s . S t a r c h as percent t o t a l carbohydrate Hypothesis 5 was not accepted as no c o r r e l a t i o n was found between s t a r c h as percent t o t a l carbohydrate and the presence of h y p e r l i p o p r o t e i n e m i a . I t i s now g e n e r a l l y accepted t h a t a h i g h sucrose content i n the d i e t has a more h y p e r l i p i d e m i c e f f e c t that a h i g h s t a r c h c o n t e n t . T h i s was not observed i n the present study. However, m u l t i v a r i a t e a n a l y s i s o f the d i e t a r y f a c t o r s w i l l be conducted to i n v e s t i -gate the i n t e r r e l a t i o n s h i p s between the d i e t a r y v a r i a t e s and the presence of h y p e r l i p o p r o t e i n e m i a . Fat as percent t o t a l c a l o r i e s An excess of d i e t a r y f a t i s c o n s i d e r e d a p o s s i b l e r i s k f a c t o r f o r h y p e r l i p o p r o t e i n e m i a (Sherwin, 1974; Kannel, 1971). T h i s view i s not supported by the f i n d i n g s of the present study and h y p o t h e s i s 2 must be r e j e c t e d . 87 P:S r a t i o The polyunsaturated to sa t u r a t e d f a t t y a c i d r a t i o has been c i t e d as an important f a c t o r i n the presence of hyper-l i p o p r o t e i n e m i a ( L i t t l e e_t al_. , 1970; A l b r i n k , 1974; Anderson, Grande and Keys, 1973). No r e l a t i o n s h i p was shown to e x i s t between the d i e t a r y P:S r a t i o and the combined c r i t e r i o n v a r i a b l e s . As a r e s u l t of t h i s f i n d i n g hypothesis 3 i s r e j e c t e d . L i t t l e et a l . (1970) suggested that sucrose i s h y p e r l i p i -demic only i n d i e t s c o n t a i n i n g predominantly s a t u r a t e d f a t t y a c i d s and l a r g e amounts of c h o l e s t e r o l . T herefore, m u l t i -v a r i a t e a n a l y s i s of the d i e t a r y v a r i a t e s i s necessary to e s t a b l i s h the e x i s t e n c e , i f any, of i n t e r r e l a t i o n s h i p s between the d i e t a r y f a c t o r s when observing t h e i r a s s o c i a t i o n w i t h the presence of h y p e r l i p o p r o t e i n e m i a . A l c o h o l as percent t o t a l c a l o r i e s No r e l a t i o n s h i p was found between a l c o h o l as percent t o t a l c a l o r i e s and the presence of h y p e r l i p o p r o t e i n e m i a thereby making necessary the r e j e c t i o n of hypothesis 7. L i t t l e et a l . (1970) proposed that the h y p e r l i p i d e m i c e f f e c t of a l c o h o l may depend on the proportions of d i e t a r y s a t u r a t e d and unsaturated f a t . Therefore, i t would be of i n t e r e s t t o observe the r e l a t i o n s h i p between a l c o h o l content plus other d i e t a r y f a c t o r s and the presence of h y p e r l i p o p r o t e i n e m i a . 88 C i g a r e t t e smoking As o n l y three of the s u b j e c t s smoked a pipe and no sub-j e c t smoked a c i g a r , a n a l y s i s was conducted u s i n g o n l y the data r e l a t e d to c i g a r e t t e smoking. No r e l a t i o n s h i p was found between c i g a r e t t e smoking and the presence of h y p e r l i p o p r o t e i n -emia. Hypothesis 9 was t h e r e f o r e r e j e c t e d . T o t a l c a l o r i c i n t a k e The r e l a t i o n s h i p of d i e t a r y c a l o r i e s to the presence o f h y p e r l i p o p r o t e i n e m i a was found to be n o n - s i g n i f i c a n t i n the present study by the Pearson product moment c o r r e l a t i o n co-e f f i c i e n t a n a l y s i s . A l s o , although ponderal index was found to be n e g a t i v e l y r e l a t e d to the presence of h y p e r l i p o p r o t e i n -emia, no r e l a t i o n s h i p c o u l d be seen between c a l o r i c i n t a k e and ponderal index. A r e l a t i o n s h i p between o b e s i t y and plasma l i p i d s has been demonstrated by s e v e r a l r e s e a r c h e r s ( O l e f s k y , Reaven and Farquahar, 1974 a,b; H a l l e_t aJ_. , 1972) Age No c o r r e l a t i o n c o u l d be seen between age and the presence of h y p e r l i p o p r o t e i n e m i a u s i n g the t - t e s t . T h i s i s an i n t e r -e s t i n g o b s e r v a t i o n as 56% of the respondents were w i t h i n the 50-59 year age-group which, a c c o r d i n g to Lewis et a l . , (1974), tends to have the h i g h e s t t r i g l y c e r i d e and c h o l e s t e r o l con-c e n t r a t i o n s . Again, the reason f o r t h i s r e s u l t c o u l d have been the s m a l l p o p u l a t i o n used f o r the study. 89 Family h i s t o r y o f heart d i s e a s e A f a m i l y h i s t o r y of heart d i s e a s e was r e p o r t e d by 67% of the p a r t i c i p a n t s . As h y p e r l i p o p r o t e i n e m i a has been shown to be f a m i l i a l (Glueck et a l . , 1974; G o l d s t e i n et a l . , 1973; F r e d r i c k s o n e_t a_l. , 1973), i t i s s u r p r i s i n g to note that no r e l a t i o n s h i p e x i s t e d i n t h i s study between f a m i l y h i s t o r y of heart d i s e a s e and the presence of h y p e r l i p o -p r o t e i n e m i a . A n a l y s i s of the R e l a t i o n s h i p of S e l e c t e d V a r i a t e s to the I n d i v i d u a l C r i t e r i o n V a r i a b l e s The Pearson product moment c o r r e l a t i o n c o e f f i c i e n t was employed to e s t a b l i s h the c o r r e l a t i o n between suggested r i s k f a c t o r s of h y p e r l i p o p r o t e i n e m i a and the i n d i v i d u a l c r i t e r i o n v a r i a b l e s (Table XXIV). 90 TABLE XXIV PEARSON PRODUCT MOMENT CORRELATION COEFFICIENTS FOR SELECTED VARIATES AND THE CRITERION VARIABLES V a r i a b l e C o e f f i c i e n t Cases S i g n i f i c a n c e P 0.05 T r i g l y c e r i d e s and percent a l c o h o l 0.1858 64 N.S. T r i g l y c e r i d e s and age 0.2081 64 N.S. C h o l e s t e r o l and age 0.2482 64 s. T r i g l y c e r i d e s and ponderal index -0.3911 64 s. C h o l e s t e r o l and pondera l index -0.3086 64 s. T r i g l y c e r i d e s and b l o o d g l u c o s e 0.3740 64 s. T r i g l y c e r i d e s and e x e r c i s e -0.1833 64 N.S. C h o l e s t e r o l and e x e r c i s e -0.3644 64 S -T r i g l y c e r i d e s and percent f a t -0.2026 64 N.S. T r i g l y c e r i d e s and a l c o h o l as percent t o t a l c a l o r i e s No r e l a t i o n s h i p was d i s c o v e r e d between a l c o h o l as per-cent t o t a l c a l o r i e s and the serum t r i g l y c e r i d e c o n c e n t r a t i o n 91 (see Appendix C ) . T h i s does not support A l b r i n k ' s (1974) s u g g e s t i o n that a l c o h o l may r a i s e t r i g l y c e r i d e l e v e l s . A l s o no a s s o c i a t i o n was observed between a l c o h o l as percent t o t a l c a l o r i e s and- the serum c h o l e s t e r o l c o n c e n t r a t i o n which compares wi t h the f i n d i n g s of B a l a r t et a l . (1974). These r e s u l t s i n f l u e n c e d the c o r r e l a t i o n between a l c o h o l as percent t o t a l c a l o r i e s and the presence of h y p e r l i p o p r o t e i n e m i a thereby c a u s i n g the r e j e c t i o n of h y p o t h e s i s 7. T r i g l y c e r i d e s and age Levy (1973) s t a t e d t h a t the c o n c e n t r a t i o n of a l l serum l i p i d s i n c r e a s e s w i t h age. T h i s statement i s not upheld by the f i n d i n g s of the prese n t study as no r e l a t i o n s h i p was observed between age and the serum t r i g l y c e r i d e l e v e l s . C h o l e s t e r o l and age The p o s i t i v e c o r r e l a t i o n observed between the serum c h o l e s t e r o l c o n c e n t r a t i o n and age p a r t i a l l y s u p p o r ts the s u g g e s t i o n t h a t the serum l i p i d l e v e l s i n c r e a s e w i t h age (Levy, 1973). T r i g l y c e r i d e s and Ponderal Index The r e s u l t of the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t a n a l y s i s s u b s t a n t i a t e s the s i g n i f i c a n t n e g ative r e l a t i o n s h i p between t r i g l y c e r i d e c o n c e n t r a t i o n and ponderal index r e v e a l e d by t - t e s t a n a l y s i s . C h o l e s t e r o l and ponderal index The negative r e l a t i o n s h i p observed between the serum c h o l e s t e r o l c o n c e n t r a t i o n and the ponderal index supports the r e s u l t o f a n a l y s i s of t - d i s t r i b u t i o n between ponderal index and the presence of h y p e r l i p o p r o t e i n e m i a . T r i g l y c e r i d e c o n c e n t r a t i o n and blood glucose S c h o n f i e l d et a l . (1974) suggested t h a t carbohydrate, l i p i d and l i p o p r o t e i n metabolism are c l o s e l y r e l a t e d . From the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t i t can be seen that a p o s i t i v e c o r r e l a t i o n e x i s t s between the f a s t i n g blood glucose l e v e l and the serum t r i g l y c e r i d e con-c e n t r a t i o n . O l e f s k y , Reaven and Farquahar (1974 b) s t u d i e d the r o l e of o b e s i t y i n c a u s i n g i n s u l i n r e s i s t a n c e . They hypo-t h e s i z e d t h at i n s u l i n r e s i s t a n c e caused by o b e s i t y l e a d to e l e v a t e d plasma t r i g l y c e r i d e l e v e l s through a c c e l e r a t e d h e p a t i c t r i g l y c e r i d e p r o d u c t i o n . In t h i s study: a. No r e l a t i o n s h i p e x i s t s between f a s t i n g blood glucose and ponderal index. b. A negative r e l a t i o n s h i p e x i s t s between ponderal index and the serum t r i g l y c e r i d e c o n c e n t r a t i o n . c. A p o s i t i v e r e l a t i o n s h i p e x i s t s between f a s t i n g blood glucose and the serum t r i g l y c e r i d e c o n c e n t r a t i o n . T h e r e f o r e , i n the present study, the h y p o t h e s i s of 93 O l e f s k y , Reaven and Farquakar (1974 b) would appear to be p a r t i a l l y supported. Overweight, as d e f i n e d by a pond e r a l index l e s s than 12.5 ( N u t r i t i o n Canada, 1973), i s not a s s o c i -ated w i t h f a s t i n g b l o o d glucose i n t h i s study. However, overweight i s a s s o c i a t e d with the serum t r i g l y c e r i d e concen-t r a t i o n as i s the f a s t i n g blood glucose l e v e l . E x e r c i s e and t r i g l y c e r i d e c o n c e n t r a t i o n No s i g n i f i c a n t r e l a t i o n s h i p was observed between the t r i g l y c e r i d e c o n c e n t r a t i o n and p h y s i c a l a c t i v i t y at the 0.05 l e v e l of s i g n i f i c a n c e . E x e r c i s e and serum c h o l e s t e r o l c o n c e n t r a t i o n The r e l a t i o n s h i p shown, with the use of the t - t e s t , between the presence of h y p e r l i p o p r o t e i n e m i a and p h y s i c a l a c t i v i t y i s supported by the negative r e l a t i o n s h i p which e x i s t s between e x e r c i s e and serum c h o l e s t e r o l c o n c e n t r a t i o n . T r i g l y c e r i d e c o n c e n t r a t i o n and f a t as percent t o t a l c a l o r i e s In the present study no s i g n i f i c a n t r e l a t i o n s h i p i s shown between t r i g l y c e r i d e c o n c e n t r a t i o n and f a t as percent t o t a l c a l o r i e s and s i m i l a r l y no r e l a t i o n s h i p has been r e v e a l e d between f a t as percent t o t a l c a l o r i e s and the serum c h o l e s t e r o l l e v e l (see Appendix C ) . In a d d i t i o n , c a l o r i e i n t a k e does not appear to be a s s o c i a t e d w i t h serum t r i g l y c e r i d e c o n c e n t r a t i o n or serum c h o l e s t e r o l c o n c e n t r a t i o n . S i m i l a r l y P:S r a t i o i s not r e l a t e d to t r i g l y c e r i d e c o n c e n t r a t i o n or c h o l e s t e r o l c o n c e n t r a t i o n 94 i n t h i s study (see Appendix C ) . Smoking As 42% of the s u b j e c t s were ex-smokers, i t was c o n s i d e r e d of i n t e r e s t t o i n v e s t i g a t e the r e l a t i o n s h i p of both ex-smokers and current-smokers to the i n d i v i d u a l t r i g l y c e r i d e and c h o l e s t e r o l l e v e l s . No c o r r e l a t i o n was found between e i t h e r ex-smokers or smokers and the t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n (see Appendix C ) . Smoking ha s been suggested as a r i s k f a c t o r o r coronary heart d i s e a s e (Kannel et a l . , 1964; Sherwin, 1974; L i t t l e , 1974). Sherwin (1974) observed t h a t a low r i s k of coronary heart d i s e a s e e x i s t e d among ex-smokers . The data from the present study, as w e l l as not d i s -p l a y i n g a r e l a t i o n s h i p between ex-smokers and the presence of h y p e r l i p o p r o t e i n e m i a , e x h i b i t e d very l i t t l e d i f f e r e n c e between ex-smokers and smokers and t h e i r a s s o c i a t i o n w i t h the presence of h y p e r l i p o p r o t e i n e m i a . A n a l y s i s of v a r i a n c e was conducted to observe i f any d i f f e r e n c e e x i s t e d between smokers, ex-smokers and non-smokers and t h e i r serum t r i g l y c e r i d e c o n c e n t r a -t i o n . Very l i t t l e d i f f e r e n c e was seen between the measures of c e n t r a l tendency i n these three groups (Table XXV). The d i f f e r e n c e beween these measures was shown to be n o n - s i g n i f i -cant at the 5% s i g n i f i c a n c e l e v e l . 95 TABLE XXV TRIGLYCERIDE CONCENTRATION OF NON-SMOKERS, EX-SMOKERS AND SMOKERS Group Number T r i g l y c e r i d e c o n c e n t r a t i o n (mg./100ml.) Mean S.D. Non-smokers 15 164.2667 - 57.1546 Ex-smokers 27 207.0741 t 102.5539 Smokers 22 170.8182 i 69.9017 T o t a l 64 Table XXVI shows a s i m i l a r o b s e r v a t i o n was made when the same procedure was conducted u s i n g c h o l e s t e r o l c o n c e n t r a -t i o n as the c r i t e r i o n v a r i a b l e . The d i f f e r e n c e between smokers, ex-smokers and non-smokers was n o n - s i g n i f i c a n t at the 0.05 l e v e l o f s i g n i f i c a n c e . TABLE XXVI CHOLESTEROL CONCENTRATION OF NON-SMOKERS, EX-SMOKERS AND SMOKERS Group • Number C h o l e s t e r o l (mg c o n c e n t r a t i o n ./100ml.) Mean S.D. Non-smokers 15 201.5333 + 29.7319 Ex-smokers 27 212.9259 + 29.2982 Smokers 22 206.9545 + 28.2379 T o t a l 64 96 M u l t i v a r i a t e A n a l y s i s o f the R e l a t i o n s h i p Between the V a r i a t e s and the Presence o f Hy p e r l i p o p r o t e i n e m i a M u l t i v a r i a t e c a n o n i c a l c o r r e l a t i o n a n a l y s i s was conducted to determin the r e l a t i o n s h i p between s e l e c t e d combinations of the v a r i a t e s and the presence of h y p e r l i p o p r o t e i n e m i a . (Table XXVII). TABLE XXVII CANONICAL CORRELATIONS INDICATING THE RELATIONSHIP BETWEEN SELECTED COMBINATIONS OF THE VARIATES AND THE CRITERION VARIABLES V a r i a b l e s C a n o n i c a l c o r r e l a t i o n s S i g n i f i c a n c e P 0.05 T r i g l y c e r i d e s , c h o l e s t e r o l , percent sucrose and blood glucose 0.38246 s. T r i g l y c e r i d e s , c h o l e s t e r o l , percent s t a r c h and blood glucose 0.37440 N.S. T r i g l y c e r i d e s , c h o l e s t e r o l , p ercent sucrose and P:S r a t i o 0.14526 N.S. T r i g l y c e r i d e s , c h o l e s t e r o l , p ercent sucrose and percent f a t 0.28366 N.S. T r i g l y c e r i d e s , c h o l e s t e r o l , p ercent a l c o h o l , percent s u c r o s e , P:S r a t i o 0.22999 N.S. T r i g l y c e r i d e s , c h o l e s t e r o l , p ercent f a t and P:S r a t i o 0.28922 N.S. T r i g l y c e r i d e s , c h o l e s t e r o l , p onderal index and e x e r c i s e 0.48464 s. T r i g l y c e r i d e s , c h o l e s t e r o l , p o n d e r a l index, e x e r c i s e , p ercent f a t and percent a l c o h o l 0.48534 s. T r i g l y c e r i d e s , c h o l e s t e r o l , p o n d e r a l index, e x e r c i s e , percent f a t , percent a l c o h o l and c a l o r i e s 0.49738 s. 97 Sucrose as percent t o t a l carbohydrate and blood glucose The d i e t a r y i n t a k e of sucrose has been suggested as a r i s k f a c t o r to the presence of h y p e r l i p o p r o t e i n e m i a (Kaufmann and K a p i t u l n i k , 1972; Bolzana et a l . , 1972). Non r e l a t i o n s h i p between t h i s i n d i v i d u a l v a r i a t e and the c r i t e r i o n v a r i a b l e s was r e v e a l e d by a n a l y s i s of t - d i s t r i b u -t i o n . M u l t i v a r i a t e a n a l y s i s was conducted t o determine the r e l a t i o n s h i p of sucrose as percent t o t a l carbohydrate p l u s f a s t i n g blood glucose to the c r i t e r i o n v a r i a b l e s . The c a n o n i c a l c o r r e l a t i o n of t h i s r e l a t i o n s h i p was found to be s i g n i f i c a n t at the 0.039 l e v e l . However, i t would appear from the i n d i v i d u a l c o e f f i c i e n t s t h a t t h i s c o r r e l a t i o n i s mainly i n f l u e n c e d by the f a s t i n g b l o o d glucose r a t h e r than the d i e t a r y i n t a k e of s u c r o s e . S t a r c h as p e r c e n t t o t a l carbohydrate p l u s b l o o d g l u c o s e A s i m i l a r r e l a t i o n s h i p was r e s e a r c h e d between s t a r c h as percent t o t a l carbohydrate p l u s f a s t i n g blood glucose and the c r i t e r i o n v a r i a b l e s ( t r i g l y c e r i d e and c h o l e s t e r o l con-c e n t r a t i o n s ) . The c a n o n i c a l c o r r e l a t i o n o b t a i n e d here was found t o be n o n - s i g n i f i c a n t at the 0.05 l e v e l . I t has been suggested t h a t a h i g h carbohydrate i n t a k e tends to e l e v a t e plasma t r i g l y c e r i d e l e v e l s , h i g h sucrose and glucose having a more h y p e r l i p i d e m i c e f f e c t t han a h i g h s t a r c h i n t a k e ( N i k k i l a and K e k k i , 1973). T h e r e f o r e , the f a c t that 98 s u c r o s e as percent t o t a l carbohydrate and f a s t i n g b l o o d glucose were found i n t h i s study t o be r e l a t e d to the c r i t e r i o n v a r i a b l e s w h i l e s t a r c h as percent t o t a l carbohydrate p l u s f a s t i n g b l o o d glucose were not i s an i n t e r e s t i n g o bserva-t i o n . Although hypotheses one and f i v e were r e j e c t e d , i t does appear that the d i e t a r y sucrose may have a r o l e to p l a y i n de t e r m i n i n g the blo o d l i p i d l e v e l s . However, the. r e l a t i o n -s h i p i s not c l e a r . From these o b s e r v a t i o n s i t would appear th a t the combination of v a r i o u s r i s k f a c t o r s , i n c l u d i n g d i e t a r y sucrose and s t a r c h , i s important when s t u d y i n g the p o s s i b l e determinants of h y p e r l i p o p r o t e i n e m i a . Sucrose as percent t o t a l carbohydrate and P:S r a t i o The i n d i v i d u a l d i e t a r y v a r i a t e s were found to be un-r e l a t e d t o the c r i t e r i o n v a r i a b l e s by a n a l y s i s o f t - d i s t r i -b u t i o n . T h e r e f o r e , the r e l a t i o n s h i p between combinations of d i e t a r y f a c t o r s and the blo o d l i p i d l e v e l s were i n v e s t i -gated t o observe i f an accumulative e f f e c t of the d i e t a r y v a r i a t e s was p r e s e n t . The c a n o n i c a l c o r r e l a t i o n between sucrose as percent t o t a l carbohydrate p l u s P:S r a t i o and the c r i t e r i o n v a r i a b l e s was found to be n o n - s i g n i f i c a n t at the 0.05 l e v e l . In a d d i t i o n , a n a l y s i s o f the data o b t a i n e d i n t h i s study does not i n d i c a t e any r e l a t i o n s h i p between the P:S r a t i o and serum t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n . 99 Sucrose as percent t o t a l carbohydrate p l u s f a t as percent c a j _ 0 1 - i e s No r e l a t i o n s h i p was observed between these v a r i a t e s and the c r i t e r i o n v a r i a b l e s when t r e a t e d by c a n o n i c a l c o r r e l a t i o n a n a l y s i s . A l c o h o l as percent c a l o r i e s , sucrose as percent t o t a l carbo-hydrate and P:S r a t i o M u l t i v a r i a t e a n a l y s i s showed no s i g n i f i c a n t c o r r e l a t i o n between these v a r i a t e s and the c r i t e r i o n v a r i a b l e s at the 5% l e v e l of s i g n i f i c a n c e . S i m i l a r l y , the three d i e t a r y v a r i a t e s when observed i n d i v i d u a l l y by Pearson product moment c o r r e l a -t i o n c o e f f i c i e n t were found to be u n r e l a t e d to e i t h e r t r i g l y -c e r i d e or c h o l e s t e r o l c o n c e n t r a t i o n . Fat as percent t o t a l c a l o r i e s and P:S r a t i o No s i g n i f i c a n t r e l a t i o n s h i p at the 0.05 l e v e l of s i g n i f i -cance was found between these v a r i a t e s and the c r i t e r i o n v a r i a b l e s u s i n g c a n o n i c a l c o r r e l a t i o n a n a l y s i s . A l s o the two d i e t a r y f a c t o r s , when observed i n d i v i d u a l l y , were found to be u n r e l a t e d t o e i t h e r t r i g l y c e r i d e o r c h o l e s t e r o l concen-t r a t i o n o r t o h y p e r l i p o p r o t e i n e m i a . T h e r e f o r e , the a n a l y s i s of the data o b t a i n e d i n t h i s study does not support the view th a t f a t as percent t o t a l c a l o r i e s and/or P:S r a t i o are r e l a t e d t o the presence of h y p e r l i p o p r o t e i n e m i a (Kannel, 1971; Sherwin, 1974). 100 Ponderal index and e x e r c i s e A s i g n i f i c a n t r e l a t i o n s h i p was observed when the t r i -g l y c e r i d e p l u s c h o l e s t e r o l c o n c e n t r a t i o n and ponderal index p l u s e x e r c i s e were,studied as two separate s e t s of v a r i a b l e s . The e i g e n v a l u e of t h i s r e l a t i o n s h i p was 0.23487 thereby showing that approximately 23% of the v a r i a n c e of t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n was accounted f o r by the ponde r a l index and e x e r c i s e . T h i s f u r t h e r supports the s t r o n g r e l a -t i o n s h i p (observed by a n a l y s i s of t - d i s t r i b u t i o n ) o f pond e r a l index and e x e r c i s e t o the presence of h y p e r l i p o p r o t e i n e m i a . Ponderal index, e x e r c i s e , percent f a t and percent a l c o h o l When the r e l a t i o n s h i p of ponde r a l index, e x e r c i s e , f a t as percent t o t a l c a l o r i e s and a l c o h o l as percent t o t a l c a l o r i e s to t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n was i n v e s t i g a t e d by c a n o n i c a l c o r r e l a t i o n the a s s o c i a t i o n was found to be s i g -n i f i c a n t . However, the e i g e n v a l u e was approximately the same as when onl y ponderal index and e x e r c i s e were used as the v a r i a b l e s o f the second s e t . T h i s suggests that the s i g n i -f i c a n t r e l a t i o n s h i p found here was mainly due to the e f f e c t o f p o n d e r a l index and e x e r c i s e r a t h e r than to the d i e t a r y i n t a k e of f a t and a l c o h o l . Percent f a t , percent a l c o h o l , c a l o r i e s , e x e r c i s e and ponderal index The e i g e n v a l u e o f the c o r r e l a t i o n between the f i r s t s et of c a n o n i c a l v a r i a b l e s ( t r i g l y c e r i d e and c h o l e s t e r o l concen-t r a t i o n ) and the second set of c a n o n i c a l v a r i a b l e s (ponderal 101 index, e x e r c i s e , f a t as percent c a l o r i e s , a l c o h o l as percent c a l o r i e s and t o t a l c a l o r i e s ) was 0.24739. T h i s was o n l y s l i g h t l y i n c r e a s e d from the value observed when o n l y p o n d e r a l index and e x e r c i s e were used as the v a r i a b l e s of the second s e t . T h i s o b s e r v a t i o n suggests t h a t , of the v a r i a b l e s s t u d i e d , p o n d e r a l index and e x e r c i s e are the major determin-ants of t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n w h i l e percent a l c o h o l , percent f a t and c a l o r i e s have l i t t l e e f f e c t . M u l t i p l e R e g r e s s i o n A n a l y s i s of the R e l a t i o n s h i p of S e l e c t e d V a r i a t e Combinations to the I n d i v i d u a l C r i t e r i o n V a r i a b l e s The r e s u l t s of m u l t i p l e r e g r e s s i o n a n a l y s i s of s e l e c t e d v a r i a t e s and the t r i g l y c e r i d e c o n c e n t r a t i o n i s shown i n Table XXVIII. Although c a l o r i e s , ponderal index and e x e r c i s e combined are shown to be a s s o c i a t e d w i t h serum t r i g l y c e r i d e c o n c e n t r a t i o n i t can be seen that t h i s e q u a t i o n i s s i g n i f i c a n t l y a f f e c t e d by the p o n d e r a l index. The F - r a t i o of the a n a l y s i s of v a r i a n c e between the p o n d e r a l index and t r i g l y c e r i d e con-c e n t r a t i o n i s s i g n i f i c a n t at the 0.05 l e v e l . T h e r e f o r e , p o n d e r a l index r a t h e r than c a l o r i e s and e x e r c i s e i s a f f e c t i n g the s i g n i f i c a n t r e l a t i o n s h i p found from the m u l t i v a r i a t e a n a l y s i s of the a s s o c i a t i o n of ponderal index, c a l o r i e s and e x e r c i s e to t r i g l y c e r i d e c o n c e n t r a t i o n . A s i m i l a r e f f e c t can be observed i n the r e l a t i o n s h i p of c a l o r i e s and p o n d e r a l index to t r i g l y c e r i d e c o n c e n t r a t i o n . T h e r e f o r e , although s e v e r a l combinations of the suggested 102 r i s k f a c t o r s of h y p e r l i p o p r o t e i n e m i a have been s t u d i e d i n t h i s survey, no composite of v a r i a t e s has been shown to have an a s s o c i a t i o n with the serum t r i g l y c e r i d e c o n c e n t r a t i o n . TABLE XXVIII MULTIPLE REGRESSION ANALYSIS SHOWING RELATIONSHIP BETWEEN SELECTED VARIATES AND THE SERUM TRIGLYCERIDE CONCENTRATION Dependant v a r i a b l e V a r i a t e s F - r a t i o S i g n i -f i c a n c e P 0.05 F - r a t i o of i n d i v i d u a l v a r i a t e s S i g n i -f i c a n c e P 0.05 T r i g l y c e r i d e s C a l o r i e s P . I . a E x e r c i s e 3.87314 s. 0.026 9.211 0.569 N.S. s. N.S. T r i g l y c e r i d e s C a l o r i e s Height 0.30111 N.S. 0.006 0.547 N.S. N.S. T r i g l y c e r i d e s C a l o r i e s P.I. 5.56439 s. 0.099 11.064 N.S. s. T r i g l y c e r i d e s C a l o r i e s Percent sucrose 0.57745 N.S. 0.312 1^ 099 N.S. T r i g l y c e r i d e s C a l o r i e s P e r c ent s t a r c h 0.15324 N.S. 0.081 0.252 N.S. N.S. T r i g l y c e r i d e s C a l o r i e s P:S r a t i o 0.03527 N.S. 0.068 0.016 N.S. N.S. T r i g l y c e r i d e s C a l o r i e s Percent f a t 1.33820 N.S. 0.063 2.620 N.S. N.S. T r i g l y c e r i d e s Percent a l c o h o l C a l o r i e s 1.15217 N.S. 2.248 0.118 N.S. N.S. ponde r a l i n d e x T Sherwin (1974) and Kannel (1971) suggested that one of the components of an a n t i - a t h e r o g e n i c d i e t s h o u l d be a f a t content of l e s s than 30% of the t o t a l c a l o r i e s . I t sho u l d 103 be noted from the above t a b l e t h a t , although i n s i g n i f i c a n t , t here i s the s u g g e s t i o n of a r e l a t i o n s h i p between f a t con-sumed as percent t o t a l c a l o r i e s and the serum t r i g l y c e r i d e c o n c e n t r a t i o n . Such a suggested a s s o c i a t i o n was not observed between d i e t a r y f a t and serum c h o l e s t e r o l c o n c e n t r a t i o n . The m u l t i p l e r e g r e s s i o n a n a l y s i s a l s o e x h i b i t e d the s u g g e s t i o n of a r e l a t i o n s h i p between a l c o h o l as percent of t o t a l c a l o r i e s and the serum t r i g l y c e r i d e c o n c e n t r a t i o n . A l b r i n k (1974) suggested that a l c o h o l may r a i s e t r i g l y c e r i d e l e v e l s . S i x t y - f o u r percent of the p a r t i c i p a n t s of t h i s study d i d not partake of any a l c o h o l . T h e r e f o r e , the f a i l u r e to f i n d a s i g n i f i c a n t c o r r e l a t i o n between a l c o h o l as percent t o t a l c a l o r i e s and the t r i g l y c e r i d e c o n c e n t r a t i o n may be due to the s m a l l percentage of the respondents e x h i b i t i n g an extremely wide range of a l c o h o l consumption. L i t t l e s i g n i f i c a n t c o r r e l a t i o n was seen between s e l e c t e d combinations of v a r i a t e s and the serum c h o l e s t e r o l c o n c e n t r a -t i o n (Table XXIX). Again p o n d e r a l index appears to have p l a y e d an important r o l e i n i n f l u e n c i n g the s i g n i f i c a n t c o r r e l a t i o n s seen when m u l t i v a r i a t e a n a l y s i s u s i n g c a l o r i e s , p o n d e r a l index and e x e r c i s e o r c a l o r i e s and po n d e r a l index data was conducted. In a d d i t i o n however, e x e r c i s e a l s o has an e f f e c t when the r e l a t i o n s h i p between c a l o r i e s , p o n d e r a l index and e x e r c i s e and the serum c h o l e s t e r o l c o n c e n t r a t i o n was s t u d i e d . T h i s f u r t h e r s t r e n g t h e n s the s i g n i f i c a n t 104 TABLE XXIX MULTIPLE REGRESSION ANALYSIS SHOWING RELATIONSHIP BETWEEN SELECTED VARIATES AND THE SERUM CHOLESTEROL CONCENTRATION Dependant V a r i a t e s F - r a t i o S i g n i - F - r a t i o of S i g n i -v a r i a b l e f i c a n c e i n d i v i d u a l f i c a n c e P 0.05 v a r i a t e s P 0.05 C h o l e s t e r o l C a l o r i e s 4 .89725 s. 0.826 N.S. P.I. 4.162 s. E x e r c i s e 5.644 s. C h o l e s t e r o l C a l o r i e s 1 .77570 N.S. 0.871 N.S. Height 1.995 N.S. C h o l e s t e r o l C a l o r i e s 4 .20390 s. 1.798 N.S. P.I. 6.734 s.. C h o l e s t e r o l C a l o r i e s 0 .77005 N.S. 1.490 N.S. Percent sucrose 0.032 N.S. C h o l e s t e r o l C a l o r i e s 0 .79870 N.S. 1.569 N.S. Percent s t a r c h 0 .088 N.S. C h o l e s t e r o l C a l o r i e s 1 .25130 N.S. 2.158 N.S. P:S r a t i o 0.971 N.S. C h o l e s t e r o l C a l o r i e s 1 .40587 N.S. 2.307 N.S. Percent f a t 1.273 N.S. C h o l e s t e r o l C a l o r i e s 0 .76170 N.S. 1.478 N.S. Percent a l c o h o l 0.016 N.S. 105 r e l a t i o n s h i p between c h o l e s t e r o l and e x e r c i s e observed by the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t a n a l y s i s -a r e l a t i o n s h i p which was not observed between e x e r c i s e and t r i g l y c e r i d e l e v e l s . L i m i t a t i o n s o f the Study The i n v e s t i g a t o r was aware of the f o l l o w i n g l i m i t a t i o n s i n t h i s study: 1. To prevent s e a s o n a l v a r i a t i o n of d i e t a r y data o b t a i n e d d u r i n g the study, i n t e r v i e w s were con-ducted d u r i n g the p e r i o d o f May 1 to October 16, 1975. T h e r e f o r e , the sample p o p u l a t i o n was r e s t r i c t e d by the number of p a t i e n t s admitted f o r c a r d i a c c a t h e t e r i z a t i o n d u r i n g that time. 2. The a t - r i s k p o p u l a t i o n i n v e s t i g a t e d i n t r o d u c e d b i a s to the study. 3. E l i m i n a t i o n of s u b j e c t s from the study was based on the c r i t e r i a e s t a b l i s h e d f o r the study. T h i s f u r t h e r reduced the amount of m a t e r i a l a v a i l a b l e f o r data a n a l y s i s . 4. I t i s u n l i k e l y t h a t s l i g h t c o r r e l a t i o n s between the v a r i a t e s and the c r i t e r i o n v a r i a b l e s w i l l be observed w i t h a p o p u l a t i o n o f s i x t y - f o u r . 5. Two types of d i e t a r y data c o l l e c t i o n had to be used due to d i f f i c u l t i e s i n c o n t a c t i n g the s u b j e c t s . H a b i t u a l p h y s i c a l a c t i v i t y i s d i f f i c u l t to assess i n a c a r d i a c a t - r i s k p o p u l a t i o n . CHAPTER V SUMMARY AND IMPLICATIONS T h i s chapter c o n t a i n s a b r i e f commentary of the pur-pose, d e s i g n and major f i n d i n g s of the study r e p o r t e d h e r e i n . C o n c l u s i o n s t h a t may be drawn and i m p l i c a t i o n s that became apparent from the i n t e r p r e t a t i o n of the f i n d i n g s w i l l a l s o be d i s c u s s e d . Summary The a s s o c i a t i o n a l study was conducted to i n v e s t i g a t e the r e l a t i o n s h i p of n u t r i t i o n a l p r a c t i c e s and r e l a t e d demo-gr a p h i c v a r i a b l e s to the presence of h y p e r l i p o p r o t e i n e m i a . The s u b j e c t s i n v e s t i g a t e d were men aged t h i r t y t o s i x t y years who had been admitted to S t . P a u l ' s H o s p i t a l f o r c a r d i a c c a t h e t e r i z a t i o n under the c a r e of Dr's A. Dodek, J Boone, D. P e r e t z and D. Kavanagh-Gray. The f o l l o w i n g o b j e c t i v e s were e s t a b l i s h e d f o r i n v e s t i -g a t i o n of the problem: 1. To determine the r e l a t i o n s h i p between the amount of s ucrose i n the d i e t , as percent of t o t a l carbo-hydrate, and the presence o f h y p e r l i p o p r o t e i n e m i a . 2. To determine the r e l a t i o n s h i p between the amount of f a t i n the d i e t , as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 107 108 3. To determine the r e l a t i o n s h i p between the P:S r a t i o i n the d i e t and the presence of h y p e r l i p o p r o t e i n e m i a . 4. To determine the r e l a t i o n s h i p between the c a l o r i c content of the d i e t and the presence of h y p e r l i p o -p r o t e i n e m i a . 5. To determine the r e l a t i o n s h i p between the amount of s t a r c h i n the d i e t , as percent of t o t a l c a rbohydrate, and the presence of h y p e r l i p o p r o t e i n e m i a . 6. To determine the r e l a t i o n s h i p between pon d e r a l index and the presence of h y p e r l i p o p r o t e i n e m i a . 7. To determine the r e l a t i o n s h i p between the amount of a l c o h o l consumed, as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 8. To determine the r e l a t i o n s h i p between p h y s i c a l a c t i v i t y and the presence of h y p e r l i p o p r o t e i n e m i a . 9. To determine the r e l a t i o n s h i p between smoking and the presence of h y p e r l i p o p r o t e i n e m i a . 10. To determine the nature of the i n t e r r e l a t i o n s h i p s between these f a c t o r s and the presence of hyper-l i p o p r o t e i n e m i a . Data c o l l e c t i o n instruments were designed f o r t h i s study to a s s e s s the n u t r i t i o n a l p r a c t i c e s , anthropometric s t a t u s and o b t a i n the r e q u i r e d demographic i n f o r m a t i o n . One i n t e r -view was conducted w i t h each s u b j e c t immediately f o l l o w i n g 109 h i s admission to h o s p i t a l . The i n t e r v i e w s were completed between May 1 and October 16, 1975. The sample c o n s i s t e d of ninety-one s u b j e c t s , twenty-seven of whom had to be e l i m i n a t e d from the study i n order to c o n t r o l b i a s . N u t r i t i o n a l p r a c t i c e s were asse s s e d from e i t h e r the f i n a l day of the three-day food r e c o r d or from the twenty-f o u r hour d i e t a r y r e c a l l . The three-day food r e c o r d or twenty-four hour r e c a l l was cross-checked w i t h a d i e t a r y h i s t o r y taken d u r i n g the i n t e r v i e w w i t h the s u b j e c t . Anthropometric s t a t u s was determined from the h e i g h t , weight, t r i c e p s k i n f o l d t h i c k n e s s and arm c i r c u m f e r e n c e measurements o b t a i n e d by the r e s e a r c h e r d u r i n g the one i n t e r v i e w conducted w i t h the s u b j e c t . The extent of p h y s i c a l a c t i v i t y h a b i t u a l l y undertaken by the s u b j e c t was assessed w i t h the a i d of a q u e s t i o n n a i r e . Data p e r t a i n i n g to smoking, f a m i l y h i s t o r y of heart d i s e a s e , age and m e d i c a t i o n s taken by the s u b j e c t were o b t a i n e d d u r i n g the i n t e r v i e w . The f a s t i n g b l o o d g l u c o s e , serum c h o l e s t e r o l and serum t r i g l y c e r i d e l e v e l s were o b t a i n e d by S t . P a u l ' s H o s p i t a l l a b o r a t o r y . The data were t r e a t e d s t a t i s t i c a l l y to t e s t the f o l l o w i n g r e s e a r c h hypotheses: 1. There w i l l be a p o s i t i v e r e l a t i o n s h i p between the amount of sucrose i n the d i e t , as percent of t o t a l c a rbohydrate, and the presence of h y p e r l i p o p r o t e i n e m i a . 110 2. There w i l l be.a p o s i t i v e r e l a t i o n s h i p between the amount of f a t i n the d i e t , as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 3. There w i l l be a ne g a t i v e r e l a t i o n s h i p between the P:S r a t i o i n the d i e t and the presence of hyper-l i p o p r o t e i n e m i a . 4. There w i l l be a p o s i t i v e r e l a t i o n s h i p between the c a l o r i c content of the d i e t and the presence of h y p e r l i p o p r o t e i n e m i a . 5. There w i l l be a ne g a t i v e r e l a t i o n s h i p between the amount of s t a r c h i n the d i e t , as percent of t o t a l , c arbohydrate, and the presence of h y p e r l i p o p r o t e i n e m i a . 6. There w i l l be a ne g a t i v e r e l a t i o n s h i p between pond-e r a l index and the presence of h y p e r l i p o p r o t e i n e m i a . 7. There w i l l be a p o s i t i v e r e l a t i o n s h i p between the amount of a l c o h o l consumed, as percent of t o t a l c a l o r i e s , and the presence of h y p e r l i p o p r o t e i n e m i a . 8. There w i l l be a ne g a t i v e r e l a t i o n s h i p between p h y s i -c a l a c t i v i t y and the presence of h y p e r l i p o p r o t e i n e m i a . 9. There w i l l be a p o s i t i v e r e l a t i o n s h i p between smoking and the presence of h y p e r l i p o p r o t e i n e m i a . The r e l a t i o n s h i p between the two c r i t e r i o n v a r i a b l e s was i n v e s t i g a t e d u s i n g the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t as was the r e l a t i o n s h i p between the v a r i a t e s . The c o r r e l a t i o n of s e l e c t e d v a r i a t e s to the presence of hyper-l i p o p r o t e i n e m i a was assessed by c o r r e l a t i o n a n a l y s i s and I l l i n v e s t i g a t i o n of the t - d i s t r i b u t i o n . A n a l y s i s of the r e l a t i o n s h i p of s e l e c t e d v a r i a t e s to the i n d i v i d u a l c r i t e r i o n v a r i a b l e s was conducted w i t h the use of the Pearson product moment c o r r e l a t i o n c o e f f i c i e n t . M u l t i v a r i a t e c a n o n i c a l c o r r e l a t i o n a n a l y s i s was used to determine the r e l a t i o n s h i p of s e l e c t e d combinations of the v a r i a t e s to the presence of h y p e r l i p o p r o t e i n e m i a . The r e l a t i o n s h i p of s e l e c t e d combinations of the v a r i a t e s to the i n d i v i d u a l c r i t e r i o n v a r i a b l e s was e x p l o r e d u s i n g m u l t i p l e r e g r e s s i o n a n a l y s i s . A l l hypotheses were t e s t e d at the 5% l e v e l of s i g n i f i c a n c e . The major f i n d i n g s of the study were: 1. 64% of the s u b j e c t s e x h i b i t e d a serum t r i g l y c e r i d e l e v e l beyond the range accepted as.normal by St. P a u l ' s H o s p i t a l l a b o r a t o r y , w h i l e o n l y 3% had abnormally high serum c h o l e s t e r o l l e v e l s . 2. A p o s i t i v e c o r r e l a t i o n between serum t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n was observed at the 0.002 l e v e l of s i g n i f i c a n c e . 3. The range of carbohydrate consumption was extremely wide extending from a d a i l y consumption of 89 gm. to 546 gm. 4. No s i g n i f i c a n t c o r r e l a t i o n was observed between the consumption of sucrose o r s t a r c h as percent carbo-112 hydrate and the presence of h y p e r l i p o p r o t e i n e m i a . A s i m i l a r o b s e r v a t i o n was made when the two c r i t e r i o n v a r i a b l e s were c o n s i d e r e d i n d i v i d u a l l y . A wide d i s p e r s i o n was observed i n f a t consumption w i t h the f a t as percent t o t a l c a l o r i e s r a n g i n g from 18.97 to 67.12%. No s i g n i f i c a n t c o r r e l a t i o n was observed between f a t as percent t o t a l c a l o r i e s and the presence of h y p e r l i p o p r o t e i n e m i a . However, d u r i n g m u l t i p l e r e g r e s s i o n a n a l y s i s the s u g g e s t i o n (between the 10 and 20% l e v e l of s i g n i f i c a n c e ) of a r e l a t i o n -s h i p between f a t as percent t o t a l c a l o r i e s and the t r i g l y c e r i d e c o n c e n t r a t i o n was seen. 95% o f the p a r t i c i p a n t s consumed a d i e t c o n t a i n i n g a P:S r a t i o of l e s s than 1. The mean P:S r a t i o observed i n the study was 0.287. No s i g n i f i c a n t c o r r e l a t i o n was observed between the d i e t a r y P:S r a t i o and the presence of hyper-l i p o p r o t e i n e m i a . The d a i l y c a l o r i c i n t a k e was extremely v a r i e d r a n g i n g from 922 to 5408 c a l o r i e s . No a s s o c i a t i o n was seen between c a l o r i e s and pond e r a l index o r c a l o r i e s and e x e r c i s e . 113 No s i g n i f i c a n t c o r r e l a t i o n was r e v e a l e d between c a l o r i c consumption and the presence of h y p e r l i p o -p r o t e i n e m i a , between c a l o r i c consumption p l u s ponderal index and the presence of h y p e r l i p o p r o t e i n emia or between c a l o r i c consumption, p o n d e r a l index p l u s e x e r c i s e and the presence o f h y p e r l i p o p r o t e i n -emia . The d i s t r i b u t i o n o f a l c o h o l consumption was very uneven. 64% of the p a r t i c i p a n t s consumed no a l c o h o l at a l l w h i l e the h i g h e s t d a i l y i n t a k e of a l c o h o l was 108 gm. No s i g n i f i c a n t c o r r e l a t i o n was i d e n t i f i e d between consumption of a l c o h o l as percent t o t a l c a l o r i e s and the presence of h y p e r l i p o p r o t e i n e m i a . However m u l t i p l e r e g r e s s i o n a n a l y s i s r e v e a l e d a s l i g h t s u g g e s t i o n (between the 10 and 20% l e v e l o f s i g n i f i cance) of a s s o c i a t i o n between a l c o h o l as percent t o t a l c a l o r i e s and the serum t r i g l y c e r i d e concen-t r a t i o n . No s i g n i f i c a n t c o r r e l a t i o n was observed between smoking and the presence of h y p e r l i p o p r o t e i n e m i a . P h y s i c a l a c t i v i t y demonstrated a n e g a t i v e r e l a t i o n -s h i p t o the presence of h y p e r l i p o p r o t e i n e m i a . 23% of the p a r t i c i p a n t s were c l a s s e d as sedentary and 28% as low moderately a c t i v e . When the 114 c r i t e r i o n v a r i a b l e s were t r e a t e d s e p a r a t e l y , a s i g n i f i c a n t c o r r e l a t i o n was observed between p h y s i c a l a c t i v i t y and c h o l e s t e r o l c o n c e n t r a t i o n , but not t r i g l y c e r i d e c o n c e n t r a t i o n . E x e r c i s e and ponde r a l index showed no c o r r e l a t i o n at the 0.05 l e v e l of s i g n i f i c a n c e but a p o s i t i v e c o r r e l a t i o n was observed at the 0.063 s i g n i f i c a n c e l e v e l . Although 67% o f the p a r t i c i p a n t s r e p o r t e d a f a m i l y h i s t o r y of heart d i s e a s e , no s i g n i f i c a n t c o r r e -l a t i o n was shown t o e x i s t i n t h i s study between f a m i l y h i s t o r y o f heart d i s e a s e and the presence o f h y p e r l i p o p r o t e i n e m i a . No s i g n i f i c a n t c o r r e l a t i o n was observed between age and the presence of h y p e r l i p o p r o t e i n e m i a . However, a p o s i t i v e c o r r e l a t i o n between age and serum c h o l e s t e r o l c o n c e n t r a t i o n was observed although no such o b s e r v a t i o n was made between age and serum t r i g l y c e r i d e c o n c e n t r a t i o n . F a s t i n g b l o o d glucose data demonstrated a p o s i t i v e c o r r e l a t i o n w i t h the presence of h y p e r l i p o p r o t e i n e m i a . When the c r i t e r i o n v a r i a b l e s were s t u d i e d i n d i v i d u -a l l y a p o s i t i v e c o r r e l a t i o n was observed between f a s t i n g b l o o d glucose and serum t r i g l y c e r i d e con-c e n t r a t i o n but no such o b s e r v a t i o n c o u l d be made 115 between f a s t i n g blood glucose and serum c h o l e s t e r o l c o n c e n t r a t i o n . 19. A negative c o r r e l a t i o n was observed between ponderal index and the presence o f h y p e r l i p o p r o t e i n e m i a . T h i s o b s e r v a t i o n was supported by i n d i v i d u a l r e l a t i o n -s h i p s of ponderal index to serum c h o l e s t e r o l and serum t r i g l y c e r i d e c o n c e n t r a t i o n s . 20. S k i n f o l d t h i c k n e s s was shown to be p o s i t i v e l y r e l a t e d t o the presence of h y p e r l i p o p r o t e i n e m i a . A r e l a t i o n -s h i p between s k i n f o l d t h i c k n e s s and p h y s i c a l a c t i v i t y was a l s o observed. 21. No s i g n i f i c a n t c o r r e l a t i o n was observed between s e l e c t e d combinations of the v a r i a t e s and the presence of h y p e r l i p o p r o t e i n e m i a . I m p l i c a t i o n s The f i n d i n g s of t h i s study w i l l be of i n t e r e s t t o the n u t r i t i o n i s t concerned w i t h the p r e v e n t i o n and treatment of coronary heart d i s e a s e . The range i n carbohydrate i n t a k e , i n c l u d i n g the type o f carbohydrate consumed, as w e l l as the wide d i s p e r s i o n i n the d i e t a r y content of f a t , i n d i c a t e s a great v a r i a t i o n i n the i n t a k e of men w i t h i n t h i s age group. In a d d i t i o n , the low P:S r a t i o observed throughout t h i s survey and the wide range o f a l c o h o l and c a l o r i c consumption r e v e a l some i n t e r e s t i n g p o i n t s to c o n s i d e r . 116 The r e s u l t s of the survey, however, a l s o i n d i c a t e t hat the r e l a t i o n s h i p of n u t r i t i o n a l f a c t o r s to the presence of h y p e r l i p o p r o t e i n e m i a must be c a r e f u l l y e v a l u a t e d . S e v e r a l a n t i - a t h e r o g e n i c d i e t a r y g u i d e l i n e s have been suggested (Committee on N u t r i t i o n , American Heart A s s o c i a t i o n , 1974; Kannel, 1971; Sherwin, 1974). The widespread p r a c t i s e of these g u i d e l i n e s would e n t a i l m a n i p u l a t i o n of the l i f e s t y l e of an e n t i r e p o p u l a t i o n . T h e r e f o r e , s t r o n g evidence of the r e l a t i o n s h i p of these d i e t a r y f a c t o r s to the presence of h y p e r l i p o p r o t e i n e m i a o r to demographic f a c t o r s which are themselves r e l a t e d t o the serum l i p i d l e v e l s i s r e q u i r e d . The anthropometric s t a t u s of the group observed suggests t h a t a l a r g e number of men w i t h i n t h i s age group c o u l d be c l a s s e d as overweight. A l s o , the p h y s i c a l a c t i v i t y data r e v e a l e d a h i g h percentage of the p a r t i c i p a n t s to be i n the sedentary or low moderately a c t i v e groups. The p r o p o r t i o n of ex-smokers among the respondents appeared to be a r e s u l t of the wide-spread p u b l i c h e a l t h e d u c a t i o n r e g a r d i n g smoking which has been undertaken i n re c e n t y e a r s . The data r e l a t e d t o l i p i d l e v e l s o b t a i n e d d u r i n g the study w i l l be of i n t e r e s t to the p h y s i c i a n . It has been suggested that the serum l e v e l s of both t r i g l y c e r i d e and c h o l e s t e r o l i n c r e a s e s w i t h age (Lewis et a l . , 1974; Levy, 1973). However, although 56% of the respondents were i n 117 the 50-59 year age-group, 64% of the s u b j e c t e x h i b i t e d abnormally h i g h serum t r i g l y c e r i d e l e v e l s w h i l e o n l y 3% showed h i g h l e v e l s of c h o l e s t e r o l . The f o l l o w i n g i m p l i c a t i o n s became apparent from the i n t e r p r e t a t i o n of the f i n d i n g s of t h i s study: 1. Serum t r i g l y c e r i d e as w e l l as c h o l e s t e r o l con-c e n t r a t i o n s h o u l d be c o n s i d e r e d when e v a l u a t i n g the a n t h e r o g e n i c s t a t u s of an i n d i v i d u a l . T h i s i m p l i c a t i o n supports the recommendation of Levy, B o n n e l l and E r n s t (1971) and Iammarino (1975). 2. Achievement and maintenance of i d e a l body weight s h o u l d be regarded as an important recommendation f o r r e d u c t i o n of the i n c i d e n c e of h y p e r l i p o p r o t e i n e m i a . 3. P h y s i c a l a c t i v i t y i s s i g n i f i c a n t l y r e l a t e d to the presence of h y p e r l i p o p r o t e i n e m i a as w e l l as to the t r i c e p s k i n f o l d t h i c k n e s s . T h e r e f o r e , t h i s f a c t o r s h o u l d be c o n s i d e r e d when e v a l u a t i n g the r i s k f a c t o r s of h y p e r l i p o p r o t e i n e m i a . 4. These two v a r i a t e s , e x e r c i s e and i d e a l body weight, p r o v i d e e x c e l l e n t p o i n t s at which i n t e r v e n t i o n be be i n t r o d u c e d . 5. A p o s i t i v e c o r r e l a t i o n was observed between f a s t i n g b l o o d glucose and serum t r i g l y c e r i d e c o n c e n t r a t i o n . T h e r e f o r e , the presence and, i f necessary, treatment 118 of h i g h serum t r i g l y c e r i d e c o n c e n t r a t i o n s h o u l d be c o n s i d e r e d i n the i n d i v i d u a l who d i s p l a y s an abnormal glucose metabolism. Recommendations f o r a d d i t i o n a l r e s e a r c h i n t h i s area i n c l u d e : 1. A survey of l a r g e r p o p u l a t i o n s i z e s h o u l d be undertaken to observe the r e l a t i o n s h i p of f a t as percent t o t a l c a l o r i e s , a l c o h o l as percent t o t a l c a l o r i e s and carbohydrate as percent t o t a l c a l o r i e s to the serum t r i g l y c e r i d e and c h o l e s t e r o l c o n c e n t r a t i o n . 2. More e x t e n s i v e a c c u r a t e food c o m p o s i t i o n t a b l e s f o r sucrose and s t a r c h s h o u l d be developed to a s s i s t i n s t u d i e s s i m i l a r to t h a t r e p o r t e d l i e r e i n . LITERATURE CITED 120 LITERATURE CITED Adams, P.W., Kissebah, A.H., H a r r i g a n , P., Stokes, T. and Wynn, V. "The K i n e t i c s of Plasma Free F a t t y A c i d and T r i g l y c e r i d e T r a n s p o r t i n P a t i e n t s w i t h I d i o p a t h i c H y p e r t r i g l y c e r i d e m i a and T h e i r R e l a t i o n to Carbohydrate Metabolism." Eur. J. C l i n . I n v e s t . 4(1974):149-161. 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APPENDIX A DATA COLLECTION INSTRUMENTS 132 FOOD RECORD F O R D A Y S NAME' ' -C O D E jffiSFR - r r ' ^ S T U D Y ' N U M B E R :  133 HQW TQ RECORD F Q Q P S P A T F N S T A T E T H E K I N D OF FOOD E A T E N : E X A M P L E S : M I L K - W H O L E / S K I M OR C H O C O L A T E / E T C , - S T A T E I F M I L K HAS V I T A M I N D A D D E D , C R E A M - W H I P P I N G , T A B L E C R E A M , C E R E A L C R E A M , C H E E S E - C H E D D A R / C H E E S E S P R E A D / C O T T A G E C H E E S E / M O Z A R E L L A . F R U I T - A P P L E S A U C E / B A N A N A , V I T A M I N I Z E D A P P L E J U I C E ORANGE J U I C E . V E G E T A B L E S - P E A S / F R I E D OR B A K E D P O T A T O E S , RAW OR COOKED C A R R O T S , B R E A D - W H I T E , WHOLE W H E A T , H O V I S , C R U S T Y R O L L , B U T T E R OR M A R G A R I N E , C E R E A L S - SUGAR P O P S , Q U I C K C R E A M OF W H E A T , S H R E D D E D W H E A T , M E A T , F I S H , P O U L T R Y , EGGS - H A M B U R G E R , S A U S A G E S , F R I E D C H I C K E N , PORK L I V E R , S C R A M B L E D E G G S , F I S H S T I C K S , COD F I L L E T S . M I S C E L L A N E O U S - STRAWBERRY J A M , S U G A R , G R A V Y , F R E N C H D R E S S I N G , P U M P K I N P I E , O A T M E A L C O O K I E S / T O F F E E / C H O C O L A T E S U N D A E , C O K E , T E A , N U T R I T I O N A L S U P P L E M E N T S - C O D - L I V E R O I L , G E R I T O L , V I T A M I N P I L L S . N O T E : I F YOU A R E NOT SURE OF T H E D E T A I L S , S T A T E T H E B R A N D N A M E . 134 S T A T E T H E AMOUNT OF FOOD E A T E N : EXAMPLES: MILK - 1 CUP/ \ PINT/ 1 SMALL OR LARGE GLASS, CREAM - 1 TABLESPOON ( i N COFFEE) CHEESE - 1 " CUBE CHEDDAR OR 1 TABLESPOON CREAM CHEESE, FRUIT - k CUP PEACHES/ 1 SMALL APPLE/ 1 SMALL GLASS GRAPEFRUIT JUICE/ 1 2 GRAPES. VEGETABLES - \ CUP TURNIP/ 2 SLICES CUCUMBER/ \ CUP COOKED CABBAGE/ 1 MEDIUM BAKED POTATO, BREAD - 2 SLICES/ 1 MEDIUM ROLL, BUTTER OR MARGARINE - 1 TABLESPOON/ 3 TEASPOONS/ 2 PATS, CEREALS - 1 CUP OATMEAL PORRIDGE/ 1 SHREDDED WHEAT BISCUIT, MEAT/ FISH/ POULTRY/ EGGS - 3 SAUSAGES/ 1 PORK CHOP 1 SMALL SERVING OF ROAST BEEF/ W CUPS BEEF STEW WITH 4 ~ 1 " CUBES BEEF (WITH \ CUP POTATOES AND \ CUP CARROTS, MISCELLANEOUS - 1 TEASPOON JAM/ 1 TABLESPOON BROWN SUGAR/ 3 OATMEAL COOKIES/ \ " WEDGE CHOCOLATE BAR ( 1 0 0 / I O C BAG OF POTATO CHIPS/ X CUP PEANUTS/ 1 BOTTLE ORANGE/ 1 CUP TEA. NUTRITIONAL SUPPLEMENT: 1 TEASPOON/ 5 DROPS/ 1 P I L L . STATE THE AMOUNT OF VITAMIN IN DOSAGE EXAMPLE: 4 0 0 I.U. VITAMIN D, 1 2 MG IRON. 135 D E S C R I B E C O M B I N A T I O N S OF FOOD E A T E N : E X A M P L E : M I L K - \ C U P M I L K ON O A T M E A L P O R R I D G E , - 1 C U P M I L K I N C R E A M OF TOMATO S O U P , C R E A M - 1 T A B L E S P O O N I N C O F F E E . C H E E S E - 1 C U P M A C A R O N I A N D C H E E S E , F R U I T - \ C U P F R U I T C U P (M O R A N G E , 3 G R A P E S ) V E G E T A B L E - \ C U P C O L E S L A W (M C U P RAW C A B B A G E , % C U P RAW C A R R O T , S A L A D D R E S S I N G ) B R E A D - 1 S A N D W I C H ( 2 S L I C E S BROWN B R E A D , W I T H M A R G A R I N E /..-• A N D 1 S L I C E OF B O L O G N A OR \ C U P EGG F I L L I N G ) C E R E A L S - \ C U P C O R N F L A K E S AND k C U P R A I S I N S . M E A T , F I S H , P O U L T R Y , E G G S ' - 1 C U P B A K E D B E A N S A N D P O R K , 1 C U P T U N A C A S S E R O L E ( N O O D L E S , P E A S A N D T U N A ) , 1 C U P B E E F MEAT L O A F WITH k C U P TOMATO S A U C E , M I S C E L L A N E O U S - \ C U P B A K E D A P P L E P U D D I N G W I T H O A T M E A L T O P P I N G , C H O C O L A T E C O A T E D 1 0 $ I C E C R E A M C O N E . N U T R I T I O N A L S U P P L E M E N T S ~ 1 P I L L WITH V I T A M I N D ( 4 0 0 I . U . ) , A ( 4 , 0 0 0 I . U . ) A N D C ( 7 5 M G ) . Day 1 N u t r i t i o n a l Supplements and M e d i c a t i o n s Day 2 N u t r i t i o n a l Supplements and M e d i c a t i o n s 138 Day 3 N u t r i t i o n a l Supplements and M e d i c a t i o n s 140 INTERVIEW FORM STUDY NO. DATE HOSPITAL NO. AGE HEIGHT WEIGHT TRICEP SKINFOLD THICKNESS CIGARETTES; YES PIPE TOBACCO:YES ARM CIRCUMFERENCE NO NO HOW LONG HOW LONG CIGARS: FAMILY HISTORY NUMBER OF PIPES PER DAY YES NO HOW LONG NO.PER DAY YES NO MEMBER OR MEMBERS MEDICATIONS HOW LONG PHYSICAL ACTIVITY: Sedentary: work and l e i s u r e . Under 5 f l i g h t s of s t a i r s or | mile walking per day How l o n g Low Moderate: Between 5 and 15 f l i g h t s of s t a i r s o r § to l | m i l e s of wal k i n g or comparable a c t i v i t y per day. How l o n g High Moderate: Programmed e x e r c i s e 4 times per week or l | to 2 m i l e s or 15 to 20 f l i g h t s of s t a i r s or comparable d a i l y a c t i v i t y How l o n g Vigorous: G r e a t e r than Moderate THERAPEUTIC DIET ( i f any) IMPRESSION OF INTERVIEW How l o n g How long BLOOD PRESSURE: DIASTOLIC FASTING SERUM TRIGLYCERIDE FASTING SERUM CHOLESTEROL FASTING BLOOD GLUCOSE SYSTOLIC o s p i t a l No. Date urvey No. Food 1 C e r e a l _2 _3 __4 5 6 7 8 9 10' H i 12: 13 14' 15" 16' 17 18' 19' 20' 21" 22 23 24' 25' 26_ 2Z_ 28 29' 30 Bread Pancakes. Cake Average P o r t i o n a a Cookies P i e R o l l s , buns, m u f f i n s Sweet R o l l s , doughnuts C r a c k e r s (any kind) Macaroni and cheese S p a g h e t t i and r i c e Beef or lamb Beef stew Ham or pork C h i l i or luncheon meat Sausage L i v e r or kidney Bacon S h e l l f i s h F i s h _ '" Sardines or tuna Chicken or jtiirkey_ F-g-g Creamed soup Whole ~mTlk 1 cup 1 s l i c e 1x6" diam, 1x2 "square 1 1/6 p i e _ 1 1 4 1 cup I cup 2 7 4 ozs . 1 jcup X X X 2rc m i l k Skim or b u t t e r m i l k 4 ozs 4 ozs. 2 ozs . 2 ozs . 2 s t r i p s 1 "cup'""" 4 ozs._ 2 ozs_. 4 ozs . 1 ~ i cup "1 cup Cheese (except C/C) M i l k d e s s e r t s 1 cup 1 cup_ Cottage cheese j 1 oz . I I c u p ! 2 CUp CO tr-1 X X \ \ - 1 — Food 31 32 33 j 34 I 35; 36 i "37 i 38 i 39! 40 ! 41 ! 42! _43 i 41' 45 I 46! 47 48 49 50 ] 51 j 52 j 53 * 54 DSi 56s 3 7 58 59 Syrup Jam or J e l l y Sugar Ice Cream B e r r i e s ( n o t s t r a w b e r r i e s ) C i t r u s j u i c e or f r u i t Other f r u i t or j u i c e Tomato or tomato j u i c e Vegetable soup Salad or c o l e s l a w Green veg. (no peas) Yellow veg. or beets Peas or c o r n Potatoes D r i e d peas or beans Candy (not c h o c o l a t e ) Candy bar ( c h o c o l a t e ) Chocolate B u t t e r Margarine Nuts and seeds Peanut b u t t e r Wine _ Soft d r i n k Average P o r t i o n O i l D r e s s i n g Mayonnaise ~ 1000 I s l a n d F r i e d F o p I "7. A l co h o i " Beer 1 tbsp. 1 t s p . 1 tbsp. I cup 1 cup I cup 5 cup I cup 1 cup 1 cup 2 CUp 2 CUp 2 CUp I cup 2 5 1 1 oz. 1 tbsp! 1 tbsp. 2 ozs . 1 tbsp, 1 tbsp. 1 tbsp. 2 ozs ._ 12 ozs 4 ozs. 4 ozs . CO j to X IX r—1 CO X X a :a a <: X -so r \ O H C ?r:oo c cup pes , APPENDIX B SUCROSE AND STARCH ESTIMATIONS 143 SUCROSE AND STARCH ESTIMATIONS Food Estimated % of Carbohydrate Content, Sucrose S t a r c h A l c o h o l 100 0 C e r e a l 0 100 Mayonnaise 0 100 Bread 0 100 Macaroni and cheese 0 100 Vegetable soup 60 40 Gravy 0 100 Chicken noodle soup 0 100 Cake - p l a i n 50 50 F r u i t p i e 50 50 Cookies 50 50 I c i n g 100 0 Rice 0 100 Carbonated Beverage 100 0 Cheese whiz 0 100 Chocolate pudding 50 50 Chocolate q u i c k 100 0 P i z z a 0 100 Jam 100 0 Chocolate bar 100 0 Lemonade 100 0 Ketchup 50 50 F l o u r 0 100 L i q u o r i c e 100 0 Spa g h e t t i sauce 50 50 Sp a g h e t t i 0 100 Tang 100 0 Cream P u f f 50 50 Pancake 50 50 O l i v e s 100 0 Doughnut 50 50 Meat P i e 0 100 Baked beans 0 100 Lasagne - used macaroni and cheese f i g u r e s . Granola - used carbohydrate content of c o r n f l a k e s p l u s 2 t s p . sugar Sweet r o l l - c a l c u l a t e d carbohydrate as 12.6 gm. s t a r c h and r e s t as s u c r o s e . APPENDIX C SCATTERGRAMS SHOWING RELATIONSHIP OF SELECTED VARIATES TO THE INDIVIDUAL CRITERION VARIABLES 21.3751 26,1908 31.006** 35,8220 40,6377 45,«!;33 50,2689 55.0846 59.9002 fed,7158 552,0000 • + 552.0000 502.7000 053,4000 aoo, IOOO 502,7000 ' 453,4000 «oa, iooo 354,8000 -3-05.50^0-256,2000 35a,8000 -JiJ5T5"^00-256,2000 206.9000 206,9000 * * * * * -157,6000-«-* * "157,-6000-108.3000 103,3000 59,0000 • 1 * I » t 59,0000 . . . . . . t . . . . + .... + .... + .-.. + .... + .... + .... + .... + .... + .... + .,.. + . . „ + .... + . „ . + .... + .... + .... + .... t.... t > 16.9673 23.7830 28.5966 -33,4142 38,2299 «J.0455 47,861 1 - 52,6768 - 57 ,492« --• 62.3080 ~ - o7,1 <!37 SCATTF.KGPAM OF (DOWN) TG (ACROSS) PF AT 21.3751 26.1908 31.0064 35.8220 40.6377 45,4533 50,2689 55.0846 59.9002 64,7158 275,0000 261,8000 - -246,6000 235,4000 222,2000 i -2^9T^0(W-195,8000 182,6000 —169,4000-156.2000 143,0000 ** » 275,0000 261,6000 26d,6000 235,4000 2^2.2000 155,8000 162,6000 -1S9.-4000-156,2000 143,0000 18.9673 2J.7830 28.5986 33.4142 -38,2299 43,0455 47.8611 - 52,6768-— 57.4924 62.3060 ~~ 67. 1237" SCATTERGRAM OF (UOhN) CHOI (ACROSS) PFAT t—1 ! 2.5000 7,5000 12,5000 17,5000 22.5000 27,5000 32,5000 37,5000 42.S000 47,5000 I ,*• 552,0000 • * • • • ^ - • • • - • , 552,0000 ^ 1 I I 1 j I • | 502,7000 • \ \ ~ " ' " " i 502,7000 i I j 053,4000 • i i • ' i i ""'453,4000 ': 404. 1000 • i i i 404,1000 1 I I i 354,6000 • * — , — _ 1 •I - i 354,9000 . ; 3-05r5OO'J—«--* i * I * i 3C5.-SCO0 256,2000 •« 2 i * \ i 256,2000 I 2 * * i j 206.9000 t * *-* * i * i \ 206,9000 13 13 157,6000 - t -• 2 i * * i i { 157,6000 * * i * I * * 108,3000 +2 5 3 3 • * I * * I * I * i * i 108,3000 I * I * I * i i 59,0000 +* * I 59,0000 0.0 5.0000 10.0000 15,0000 2 0 , 0 0 0 0 2 5 . 00 00 " 30', 00 00 - 35 ,000 0 40,0000 45,0000 50,0000 SCATTE8GHAM OF (UUkN) TG ( A C R O S S ) C1 G E T T 3 i r v : '. \ . 4.0000 9,2000 10,0000 18,6000 23,6000 28,0000 33,2000 38,0000 oa.BOOO 07,6000 1 '< 302,0000 *• 302,0000 j f j j - -i I * ^ j 1 278.00C0 i \ I * • 278,0000 ; i I 1 • 25*1,0000 ! i \ { t 250,0000 " ' | \ i w i i 230,0000 X * • 230,0000 j 1 1 [ J I i i 206,0000 \ i + ^06,0000 I /\ A Art \ i * f \ * i * 182,0000 • : 158,0000 I * i «+ 153,0000 I i * i 130,0000 I * i * + 134,0000 • -- no.oooo -| i * * X * | ; \ • +— 110,0000-•• -• 86,0000 I I * + 66,0000 \ { * I • 62,0000 • * I + ' 62,0000 • SCATURGRAM 2.0000 6.8000 OF (DOWN) TG 11,6000 - 16.U000 ' 21,2000 -'26,0000 30,6000 (ACRUSS) CIGt 35,6000 -:ns - 00,0000 ' 05,2000 "- 50,0000 - - - ' 00 V ( I ! 2.5000 7.5000 12,5000 17,5000 22,5000 27,5000 32,5000 37,5000 42,5000 47.5000 i 275,0000 V * t .•. ^ *. . +. ..... • 275.0000 ( I ! \ \ | 261,8000 \ * i j * 1 • 261,8000 ! 1 i I i i * 1 j -248,6000 j 1 | * * * i t -£08,6000 ; i ] 235,4000 I * 12 2 * .... ._ _ . . i * . . . j + 235,4000 I * * i 1 \ 222,2000 t * I * 3 i * { • 222.2000 " I * " 12 i * \ i i 2 09,0000 { 2 2 * * i * I * 209.00J0 195,8000 I * "2 2 I 2 * X • 195,3000 I * I * « • * 1 I * I * ^ ; 1E2.6000 I * * j \ t 182,6000 \ 2 * I * \ { 169,4 000 i I t 169,4000 I ! 156,2000 I * * 1 \ • 156,2000 X * I * * { I { 143,0000 SCATTERGRAM 0,0 OF 5.0000 10,0000 (DOWN) CHOI. 15,0000 2 0 , 0 0 0 0 2 5 , 0000 30,0000- 35.0000-40,000045,0000 (ACR'JSS) CXGETIS * t 143,0000 50 , 0000 — - • 4,4000 9.2000 .14,0000 16,6000 23,6000 26,4000 33,2000 36,0000 42.6000 47,6000 i 255,0000 255,0000 1 i I * j | x i 243.8000 • I j i 243,8000 I I * i 232,6000 T 1 i I \ I * } 232,6000 --221,4000 I I * j 221,4000 1 1 I I \ ! 210.2000 . • * { \ \ I 210,2000 1 !-9-9—(HM>0— \ I * * 1 j T £- ff-I 2 \ t-99rcm-o 187,6000 I * I 187,8000 I j i 1 176,6000 1 { | 176,6000 i I I * J —165,4000 -1 I I i i I * { \ { 165,4000- -I ! 154,2000 I { \ j 154.2000 ! \ | \ j • 14J.0000 SCATTERGKAM 2.0000' 6.8000 11.6000 OF (DOWN) CHOL 16,4000 21,2000--" 26,0000 • 30,8000 • 35.6000 40,4000— CACRUSS) CIGETTS 45.2000 "50,0000 143,0000 ! i v. 0.08J33 0,25000 0,41667 0,58333 0,75000 0,91667 1,08333 1,25000 1,41667 1,58333 • • + • + • + -.--• + • •---, + + • • + 1 + , 552,0000 * * 1 I • 552.0000 502,7000 453,4000 502,7000 uSi.uOUO 404,1000 40",1000 354,6000 -3«5t5<KM>-256,2000 354,80-CO 25S.20QO 206,9000 ** * . J57.600O " 206.9000 "157,6000 » * •* 108,3000 * * ** 108,3000 59,0000 • * * I I t 59,0000 • + 1 + + + 1 + + + • • + • • + „.-..*.... + +  0. 16607 0.33333 ' 0,50000 ' 0.66667 — 0,83333 1 .00000'' 1,16667~- 1 ,333 33 "~ 1 ,50 00 0" -l,6bt>fc? - • • 0.0 SCATTEKGRAM OF (L)U«N) TG (ACROSS) FARATIO 0,08333 0.25000 0,01667 275,0000 261 ,8000 208,6000 2J5.O000 222,2000 -2-O-9T©OO-O-195,8000 182,6000 169,«000-156,2000 103,0000 0,58333 0.75000 0,91667 1.08333 1,25000 1,01667 1,58333 ................... + + + + + + * 2 * * * * * * * 275,0000 261 ,6000 • 206,6000 235,0000 222,2000 "209,0000 195,6000 162,6000 169,00 00' 156,2000 103,0000 0,0 0,16667 0.33333 ' 0.50000 - 0,66667 0,63333' 1 ,00000 1 , 16667 —-I.33333 1 ,50000 1 ,06667 SCATTE3GRAM OF (UOHN) CHOL (ACROSS) FARATXO to 153 • i « i A 1146.30 1590,90 2013,50 2492,10 2940,70 3389,30 3837,90 4286,50 4735,10 5183.70 275.0000 • 261,8000 I 275,0000 261,8000 248,6000 •2U8.6000 235,4000 235,1000 222,2000 2 * -2C-»TO««*-195,8000 * • • 222.2000 -tc-9-pnrotr 195.8000 182,6000 162.6000 -169,-aOOO- -169.U000' ! 156,2000 156.2000 143,0000 t 143,0000 - -- 922,00 1370.60 1819,20 2267,80 2716,40 - 3165.00 3613. 60 •- 4062, 20" 4510 ,8 0 - 0959, 40 - • 5408» 00 " - "-SCATTER&RAM OF (U0*N) CHOL CACROSS) CAL 1.5831 «,7194 7.9157 11 ,0820 11,2*183 17,«1 a 6 20,5809 23,7472 26.9135 30,0798 552,0000 • 502,7000 I I «53.«000 - • I I 552,0000 502.7000 453,4000 I 40S.1000 + I I-I 354,8000 • * I I -I I -3-05T5-0<K) r»-I* I I» I 256,2000 +« 11 13 I * 404,1000 354,6000 "3t«T5trW 256,2000 206,9000 15 12 *3 — I» I * -13— 15 • 5 - • ! « • -I * I* 1 59,0000 •* ,+.. 0.0 SCATTERGWAM OF 206,9000 157,6000-108,3000 157;6000-108,3000 Ul Cn 59,0000 3, 1663 6,3326 ~ 9,0989 12,6652 -15,8315 18.9977' 22 .1 64 0 25 . 330 3 "28 , 49bb' ~ 31 , bb29 (UOKN) TG -CAC«USS) PALCOHOL 1,5831 0,7090 7,9157 11,0820 11,2183 17,o<06 20,5809 23.7172 28,9135 30,0798 ................ ........... ................. + +......;... . . ..—.+. 275,0000 •* 275,0000 261,8000 • 2 I * 1*-I * 235,0000 +« . . . . . j * 261,8000 208,6000 I 12 -I 222,2000 •* 10 1 2 _.. 12 - 2 0 9 - r O ~ 9 f r 9 * * -13 12 • 12 -13 195.8000 • 12-12 I--— ..... I* • 182.6000 + I* 1— I I -169,0000— .»-I r 1— 12 156,2000 • — I ••• I* 1 1— 103,0000 •* 203,6000 235,0000 222,2000 193,8000 1 8 2 , 6 0 C 0 169,0000-156.2000 103,0000 - 0.0 - 3, 1663 6.3326 ' 9,<|989 12,6652-15.6315' 18,9977 22, 1600 " " 25,3303 28.0V66 31.6629 SCATTERSWAM OF (OOwN) CHOL CACKUSS) PALCOMOL 007,0000 630,2000 813,0000 995,6000 1178,6000 1361,1000 1500,2000 1727,0000 1909,8000 2092,6000 275.0000 < *I I + 275,0000 j > 1 I 261,8000 i i ~~ • 1 i • 261,8000 | 1 1 1 1 1 | • . ~ . ^ - -- 3 /* u & 0 A n - • - •- * 208,6000 t * * — - — * j * • C^O,OUuU 235.0000 • , t  * ¥ « * i i • 235,0000 1 * 1 1 1 i 222,2000 • * * * • » * \ i * t 222,2000 '; * * * 1 * { A. ><rv q A 1 •• 1 1 . 1 2-9-9-rO-O-O-O • *»* * * * i I I i 195,8000 I*-; * ** * 1 * * + 195,8000 I » I * * 1 ** I 182,6000 • * [ « I i + 162,6000 : [ * [ * \ i 169,9000- " 1 * \ t 1 69", OOO 156,2000 I * 1 * I "+ 156.2000 -I - *- -* l 1 * ! 103,0000 • 103,0000 - 356,0000 538,8000 721,6000 900,0000 1087,2000 1270,0000 1052,8000 SCATTE»G9AM OF (DOWN) CHOI CACKUS3) CAL 635,6000""18 18,OO0 0 2001.2000 "2180.0 0 00 HO 

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