Mortality from ischemic heart disease and diabetes mellitus (type 2) in four U.S. wheat-producing states: a hypothesis-generating study.In this ecologic e·col·o·gy n. pl. e·col·o·gies 1. a. The science of the relationships between organisms and their environments. Also called bionomics. b. The relationship between organisms and their environment. study I examined ischemic heart disease Ischemic heart disease Insufficient blood supply to the heart muscle (myocardium). Mentioned in: Myocarditis ischemic heart disease (IHD IHD ischemic heart disease. ) and diabetes mortality in rural agricultural counties of Minnesota, Montana, North Dakota North Dakota, state in the N central United States. It is bordered by Minnesota, across the Red River of the North (E), South Dakota (S), Montana (W), and the Canadian provinces of Saskatchewan and Manitoba (N). , and South Dakota South Dakota (dəkō`tə), state in the N central United States. It is bordered by North Dakota (N), Minnesota and Iowa (E), Nebraska (S), and Wyoming and Montana (W). , in association with environmental exposure to chlorophenoxy herbicides, using wheat acreage as a surrogate surrogate n. 1) a person acting on behalf of another or a substitute, including a woman who gives birth to a baby of a mother who is unable to carry the child. 2) a judge in some states (notably New York) responsible only for probates, estates, and adoptions. exposure. I collected data on agricultural land use and 1979-1998 mortality from the U.S. Department of Agriculture and the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. websites, respectively. Counties were grouped based on percentage of land area dedicated to wheat farming. Poisson relative risks (RR) and 95% confidence intervals confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. (CIs), comparing high- and medium- with low-wheat counties, were obtained for IHD, the subcategories acute myocardial infarction acute myocardial infarction (  ·kyōōtˑ mī·ō·karˑ·dē· (AMl) and coronary
atherosclerosis atherosclerosis (ăth'ərōsklərō`sĭs): see arteriosclerosis. atherosclerosis or hardening of the arteries (CAS), and diabetes, adjusting for sex, age, mortality cohort cohort /co·hort/ (ko´hort) 1. in epidemiology, a group of individuals sharing a common characteristic and observed over time in the group. 2. , and poverty index. Mortality from IHD was modestly increased (RR : 1.08; 95% CI, 1.04-1.12). Analyses of its two major forms were more revealing. Compared with low-wheat counties, mortality in high-wheat counties 2from AMI increased (RR = 1.20; 95% CI, 1.14-1.26), and mortality from CAS decreased (RR = 0.89; 95% CI, 0.83-0.96). Mortality from AMI was more pronounced for those < 65 years of age (RR = 1.31; 95% CI 1.22-1.39). Mortality from type 2 diabetes type 2 diabetes n. See diabetes mellitus. increased (RR = 1.16; 95% CI, 1.08-1.24). These results suggest that the underlying cause of mortality from AMI and type 2 diabetes increased and the underlying cause of mortality from CAS decreased in counties where a large proportion of the land area is dedicated to spring and durum wheat durum wheat: see wheat. farming. Firm conclusions on causal causal /cau·sal/ (kaw´z'l) pertaining to, involving, or indicating a cause. causal relating to or emanating from cause. inference (logic) inference - The logical process by which new facts are derived from known facts by the application of inference rules. See also symbolic inference, type inference. cannot be reached until more definitive studies have been conducted. Key words: chlorophenoxy herbicides, clofibrate clofibrate /clo·fi·brate/ (-fi´brat) an antihyperlipidemic used to reduce serum lipids. clo·fi·brate n. , coronary atherosclerosis, C-reactive protein C-Reactive Protein Definition C-reactive protein (CRP) is a protein produced by the liver and found in the blood. Purpose C-reactive protein is not normally found in the blood of healthy people. , diabetes, ischemic heart disease, myocardial infarction myocardial infarction: see under infarction. . doi:10.1289/ehp.8352 available via http://dx.doi.org/[Online 6 October 2005] ********** A series of International Agency for Research on Cancer The International Agency for Research on Cancer (IARC, or CIRC in its French acronym) is an intergovernmental agency forming part of the World Health Organisation of the United Nations. Its main offices are in Lyon, France. multinational studies of workers involved in the production of chlorophenoxy herbicides and chlorophenols indicated excess mortality from cancer, ischemic heart disease (IHD), and possibly diabetes in association with 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD TCDD tetrachlorodibenzodioxin. ) exposure (Flesch-Janys et al. 1995; Hooiveld et al. 1998; Kogevinas et al. 1997; Vena et al. 1998). Chemical production workers exposed to TCDD are simultarteously exposed to much higher levels of the commercial chemicals being produced, such as chlorophenoxy herbicides and chlorophenols (Remillard and Bunce n. 1. a sudden unexpected piece of good fortune. Noun 1. bunce - a sudden happening that brings good fortune (as a sudden opportunity to make money); "the demand for testing has created a boom for those unregulated laboratories where boxes of 2002). Results from the cancer mortality study among chlorophenoxy herbicide herbicide (hr`bəsīd'), chemical compound that kills plants or inhibits their normal growth. A herbicide in a particular formulation and application can be described as selective or nonselective. production workers, some of whom were exposed to TCDD or higher chlorinated chlorinated /chlo·ri·nat·ed/ (klor´i-nat?ed) treated or charged with chlorine. chlorinated charged with chlorine. chlorinated acids some, e.g. dioxins (Kogevinas et al. 1997), were similar to those reported in an ecologic mortality study of cancer among residents in rural, agricultural counties of Minnesota, Montana, North Dakota, and South Dakota potentially exposed to chlorophenoxy herbicides and/or contaminants (Schreinemachers 2000). This similarity of results led to the question of whether increased mortality from IHD and diabetes observed among the chlorophenoxy herbicide production workers (Vena et al. 1998) might also be observed among residents of agricultural counties of Minnesota, Montana, North Dakota, and South Dakota, where the major field crops spring and durum wheat have been treated predominantly pre·dom·i·nant adj. 1. Having greatest ascendancy, importance, influence, authority, or force. See Synonyms at dominant. 2. and long term with chlorophenoxy herbicides (Lin et al. 1995). The chlorophenoxy herbicides 2,4-dichlorophenoxyacetic acid (2,4-D) and 4-chloro-2-methylphenoxyacetic acid (MCPA MCPA, MCP 2-methyl-4-chlorophenoxyacetic acid; a weedkiller reported to be nontoxic at the levels likely to be encountered on pasture, though it has killed cattle dosed experimentally with large single doses. ) have been widely applied in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. since World War II and are used for broadleaf broad·leaf adj. Broad-leaved. Adj. 1. broadleaf - having relatively broad rather than needlelike or scalelike leaves broad-leafed, broad-leaved weed control Weed control is the botanical component of pest control, stopping weeds from reaching a mature stage of growth when they could be harmful to domesticated plants and livestock by physical and chemical methods. in wheat farming and maintenance of home lawns and parks, rights-of-way, and road sides (Short and Colborn 1999). 2,4-D used for home lawn maintenance is likely to be found in residential carpet dust up to 1 year after application (Nishioka et al. 1996). Chlorophenoxy herbicides are present in agricultural and urban streams and in the atmosphere [U.S. Geological Survey The term geological survey can be used to describe both the conduct of a survey for geological purposes and an institution holding geological information. A geological survey (USGS USGS United States Geological Survey (US Department of the Interior) ) 1995, 2003]. 2,4-D and MCPA are transported over short and long distances attached to air particles, with concentrations highest in regions where they are applied at the time of application (Waite et al. 2002, 2005). Contaminants present in technical-grade 2,4-D and MCPA include polychlorinated dibenzodioxins and dibenzofurans and 2,4-dichlorophenol [U.S. Department of Agriculture (USDA USDA, n.pr See United States Department of Agriculture. ) 1998]. More recently, aryl ar·yl n. An organic radical derived from an aromatic compound by the removal of one hydrogen atom. hydrocarbon hydrocarbon (hī'drōkär`bən), any organic compound composed solely of the elements hydrogen and carbon. The hydrocarbons differ both in the total number of carbon and hydrogen atoms in their molecules and in the proportion of hydrogen receptor-based assays for dioxin-like activity of chlorinated herbicides applied in the Minnesota Red River Valley
The Red River Valley is a region in central North America that is drained by the Red River of the North. showed that most of these commercial-grade mixtures had measurable dioxin-like activity (Huwe et al. 2003). Confirmatory analytic an·a·lyt·ic or an·a·lyt·i·cal adj. 1. Of or relating to analysis or analytics. 2. Expert in or using analysis, especially one who thinks in a logical manner. 3. Psychoanalytic. chemical studies showed that some of the 2,4-D ester formulations were contaminated contaminated, v 1. made radioactive by the addition of small quantities of radioactive material. 2. made contaminated by adding infective or radiographic materials. 3. an infective surface or object. with dioxins/furans, including trace amounts of TCDD. Residents of agricultural counties of Minnesota, Montana, North Dakota, and South Dakota may be environmentally and/or occupationally exposed to 2,4-D and MCPA. Wheat acreage per county or percentage of the county's land area dedicated to wheat farming was used in two previous ecologic studies as a surrogate measure of exposure to chlorophenoxy herbicides and/or contaminants, because information on herbicide use by county was not available (Schreinemachers 2000, 2003). Use of this surrogate exposure measure was a reasonable choice because chlorophenoxy herbicides are the predominant pre·dom·i·nant adj. 1. Having greatest ascendancy, importance, influence, authority, or force. See Synonyms at dominant. 2. herbicides applied to wheat and because other major field crops in these four states, corn and soybeans, are mostly treated with other herbicides, based on information on herbicide use by crop, state, and year, available since 1991 (USDA 1991). Before 1991, information on herbicide use was available only for groups of states. In the present ecologic study I investigated the possible links between environmental exposures to chlorophenoxy herbicides and mortality during 1979-1988 and 1989-1998 from IHD and type 2 diabetes. Counties with different levels of wheat farming provided a gradient gradient In mathematics, a differential operator applied to a three-dimensional vector-valued function to yield a vector whose three components are the partial derivatives of the function with respect to its three variables. The symbol for gradient is ∇. of exposures, thereby overcoming the lack of a null A character that is all 0 bits. Also written as "NUL," it is the first character in the ASCII and EBCDIC data codes. In hex, it displays and prints as 00; in decimal, it may appear as a single zero in a chart of codes, but displays and prints as a blank space. referent ref·er·ent n. A person or thing to which a linguistic expression refers. Noun 1. referent - something referred to; the object of a reference . This hazard identification study can be one of the initial steps in defining an association between environmental exposures to chlorophenoxy herbicides and mortality from IHD and diabetes. Materials and Methods Mortality. I obtained data on underlying cause of death based on the International Classification of Diseases, 9th Revision (ICD-9) (U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS 1989) by state, county, sex, and age group for 1979-1988 and 1989-1998 for Minnesota, Montana, North Dakota, and South Dakota [Centers for Disease Control and Prevention (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ) 2004a]. Deaths were distributed by 5-year age groups for mortality < 25 years of age and by 10-year age groups for mortality [greater than or equal to] 25 years of age. Mortality data for the following diseases were extracted: IHD (ICD-9 410-414.9), acute myocardial infarction (AMI; ICD-9 410), coronary atherosclerosis (CAS; ICD-9 414.0), and diabetes mellitus diabetes mellitus Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia). (all types, ICD-9 250.0-250.9). Population data were obtained from the Population Census (CDC 2003). Only white subjects were included because the percentage of nonwhites in these states (< 10%) was too small to support reliable analyses. This study analyzed an·a·lyze tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es 1. To examine methodically by separating into parts and studying their interrelations. 2. Chemistry To make a chemical analysis of. 3. publicly available data sets and was exempt from institutional review board approval. Agricultural data. From the combined 262 counties of the four states, agricultural counties with a mostly rural population were selected based on the criteria of [greater than or equal to] 20% of county's land area dedicated to cropland crop·land n. Land that is fit or used for growing crops. and [greater than or equal to] 50% of population defined as rural (U.S. Census Bureau Noun 1. Census Bureau - the bureau of the Commerce Department responsible for taking the census; provides demographic information and analyses about the population of the United States Bureau of the Census 1980a; USDA 1982). Rural populations living in agricultural counties are more likely to be exposed to agricultural chemicals than are urban populations. Farming communities tend to be more residentially stable than urban communities (Blair and Zahm 1995). Although farmers and their families may have been exposed to higher levels of pesticides than the general rural population, it was not possible to distinguish between farmers and nonfarmers. Averages of total wheat acreage per county were determined for 1970-1979, 1980-1989, and 1990-1999, based on annual estimates of total wheat acreages per county (USDA 2004). Wheat acreage for 1964 was obtained from the 1964 USDA Agricultural Census (USDA 1964). To further define wheat acreage in rural, agricultural counties of Minnesota, Montana, North Dakota, and South Dakota as a surrogate for chlorophenoxy herbicide use, I determined acreage for the different classes of wheat in the selected counties. The percentage of herbicide-treated acreage for spring and durum wheat is larger than for winter wheat winter wheat n. Wheat planted in the autumn and harvested the following spring or early summer. , which is a better competitor with weeds 1. weeds - Refers to development projects or algorithms that have no possible relevance or practical application. Comes from "off in the weeds". Used in phrases like "lexical analysis for microcode is serious weeds." 2. (Lin et al. 1995). For counties with a large winter wheat acreage, I applied a correction factor to the winter wheat acreage before combining it with spring and durum wheat acreage to obtain a value for total wheat acreage. This correction factor was based on 1991-1998 herbicide treatment for the different classes of wheat (USDA 1991). This information was not available for years before 1991. Statistical methods. I used Spearman spear·man n. A man, especially a soldier, armed with a spear. correlations to determine the associations among 1964 and average 1970-1979, 1980-1989, and 1990-1999 levels of wheat acreage. Depending on the number of deaths available for the specific underlying cause under study, counties were grouped based on the median or tertiles of the percentage of land area dedicated to wheat. For diabetes mortality, I compared high-wheat counties with low-wheat counties. For mortality from IHD, including AMI and CAS, I compared high- and medium-wheat counties with low-wheat counties. For the univariate analyses by mortality cohort, sex, and age groups, I calculated standardized standardized pertaining to data that have been submitted to standardization procedures. standardized morbidity rate see morbidity rate. standardized mortality rate see mortality rate. rate ratios (SRRs) and 95% confidence interval (CI) using direct age standardization standardization In industry, the development and application of standards that make it possible to manufacture a large volume of interchangeable parts. Standardization may focus on engineering standards, such as properties of materials, fits and tolerances, and drafting based on the 1970 U.S. population, according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. established methods (Greenland and Rothman 1998). For the multivariate The use of multiple variables in a forecasting model. analyses I used Poisson regressions In statistics, the Poisson regression model attributes to a response variable Y a Poisson distribution whose expected value depends on a predictor variable x, typically in the following way: Results Wheat and chlorophenoxy herbicide use. Although the average percentage of a county's land area dedicated to wheat increased from 6.9% in 1964 to 12.1% during 1990-1999, Spearman correlations for the average 1970-1979 wheat acreage with the 1964, average 1980-1989, and average 1990-1999 wheat acreages were 0.98 (p < 0.0001), 0.95 (p < 0.0001), and 0.94 (p < 0.0001), respectively. This implied that a county with a high percentage of its land area dedicated to wheat during 1970-1979 was most likely also a high-wheat county during 1964, 1980-1989, and 1990-1999. The average total wheat acreage for 1970-1979 expressed as a percentage of a county's land area was used as a surrogate measure of exposure to chlorophenoxy herbicides. Wheat acreage during the other time periods could probably also have been used given the high correlations. A USDA report showed that in 1976, > 90% of the herbicides applied to wheat in the United States consisted of chlorophenoxy herbicides (Eichers et al. 1978). The percentage of chlorophenoxy herbicides applied overall to wheat decreased to 67% in 1992 because of increased use of other herbicides (Lin et al. 1995). I determined acreage for the different classes of wheat in the selected counties of the four states for 1970-1979. The estimated acreage of winter wheat during 1970-1979 was < 2% in the selected counties of Minnesota and North Dakota, so total wheat acreage was practically synonymous with synonymous with adjective equivalent to, the same as, identical to, similar to, identified with, equal to, tantamount to, interchangeable with, one and the same as the combined durum durum a class of wheat producing hard flour. and other spring wheat any kind of wheat sown in the spring; - in distinction from winter wheat, which is sown in autumn. See also: Spring acreage. However, the average acreage of winter wheat in the selected Montana and South Dakota counties contributed 36% and 20%, respectively, to the total wheat acreage. Given these data, it seemed appropriate to apply a correction factor to winter wheat acreage in Montana and South Dakota to account for the less intensive herbicide treatment. The amount of herbicides used on different classes of wheat has been made available for individual states since 1991. The 1991-1998 average percentage of durum and other spring wheat acreage treated with any herbicides in Minnesota, Montana, North Dakota, and South Dakota was 91%, whereas the average percentages of winter wheat in Montana and South Dakota treated with any herbicide were 86% and 67%, respectively. Assuming that the percentage of herbicide treated winter wheat acreage in Montana and South Dakota during 1991-1998 was similar to the percentage of herbicide-treated acreage during 1970-1979, a correction was applied to the 1970-1979 winter wheat acreage in counties of Montana and South Dakota, by multiplying mul·ti·ply 1 v. mul·ti·plied, mul·ti·ply·ing, mul·ti·plies v.tr. 1. To increase the amount, number, or degree of. 2. Mathematics To perform multiplication on. the winter wheat acreage by 0.95 (86/91) and 0.74 (67/91), respectively, before combining winter wheat acreage with durum and other spring wheat acreage by county to obtain a value for adjusted total wheat acreage. County characteristics. Characteristics of the 152 selected counties distributed over three groups based on tertiles of the counties' wheat percentage are presented in Table 1. Most counties in the low-wheat group were located in Minnesota, whereas counties in the high-wheat group were mostly located in North Dakota. Medium- and high-wheat counties grew less corn and soybeans than did low-wheat counties and had a larger rural and farm population size. With increasing wheat percentage, the total population size decreased, whereas the percentage of subjects [greater than or equal to] 65 years of age increased. Cardiovascular disease Cardiovascular disease Disease that affects the heart and blood vessels. Mentioned in: Lipoproteins Test cardiovascular disease and diabetes mortality. Table 2 presents crude and age-adjusted mortality rates for all ages by sex and mortality cohort. Age-adjusted U.S. rates are also presented for comparison (CDC 2004a). U.S. rates for mortality from IHD and diabetes were slightly higher than rates in the combined selected counties. Comparison of the two cohorts showed that 1989-1998 mortality from diabetes (all types) increased > 20%, whereas mortality from IHD decreased > 30%, which is consistent with the overall decline of mortality from IHD (including AMI and CAS) due to improved dietary patterns and treatment, decreased smoking, and increased physical activity (CDC 1992, 1997). Analysis of the two main subcategories of IHD revealed that age-adjusted rates for AMI among men were approximately 10% higher, and rates of CAS for both men and women were > 20% lower, in selected counties compared with the U.S. population. Age-standardized mortality rates by age group, sex, and mortality cohort are presented for IHD, AMI, and CAS, in grouped low-, medium-, and high-wheat counties, and for diabetes in grouped low- and high-wheat counties (Table 3, Figures 1-4). Wheat effects (surrogate for chlorophenoxy herbicide exposure) on IHD were slightly higher for the 1989-1998 cohort (Figure 1). These effects were more pronounced for AMI, especially for men and women < 65 years of age (Figure 2). Contrary to the increasing trend of mortality from AMI with increased wheat acreage, the trend for mortality from CAS was reversed, showing a decrease in high-wheat counties. This downward trend in deaths was observed for both mortality cohorts, both sexes, and both age groups (Figure 3), as indicated by SRR SRR Short-Range Radar SRR System Requirements Review SRR Shaped Round Robin (queuing protocol for Cisco routers) SRR Special Reconnaissance Regiment (British Army) SRR Split Ring Resonator values of < 1 and 95% CI values excluding 1. Generally, diabetes mortality was higher in high-wheat counties (Table 3, Figure 4). [FIGURES 1-4 OMITTED] The results from Poisson models adjusting simultaneously for mortality cohort, sex, age, and poverty are presented in Table 4. In high-wheat counties, mortality from IHD, AMI, and diabetes (mostly type 2 because of excluding deaths of subjects < 45 years of age) was significantly increased by 8, 20, and 16%, respectively, whereas mortality from CAS was significantly decreased by 11% (models 1-4). The mortality increase from AMI in high-wheat counties was more pronounced among subjects < 65 years (31%) than for those [greater than or equal to] 65 years of age (16%) (models 5-6). Given that chlorophenoxy herbicides use started around 1950, those that died < 65 years of age may have been exposed prenatally and/or as a child. Mortality from AMI for individual states (models 7-10) was significantly increased in Minnesota (12%), North Dakota (16%), and South Dakota (7%). The effect for Montana (6%) was not significant, which was likely due to the low number of deaths from AMI and the few and narrow range of counties. To test this possibility, I ran a separate model for Minnesota, restricted to counties in the same wheat percentage range as Montana, which resulted in a nonsignificant non·sig·nif·i·cant adj. 1. Not significant. 2. Having, producing, or being a value obtained from a statistical test that lies within the limits for being of random occurrence. wheat effect of 1.05 (0.91-1.15), similar to the results obtained for Montana. I repeated the Poisson models after applying a correction factor based on the winter wheat acreage in Montana and South Dakota. The adjusted results were very similar to the nonadjusted results (data not shown). Discussion The observed increases in mortality from IHD and diabetes in the general rural population of agricultural counties in Minnesota This is a List of counties in Minnesota. There are 87 counties in the U.S. state of Minnesota. There are also several historical counties. The original five Minnesota counties were Benton, Isanti, Ramsey, Wabasha, and Washington. , Montana, North Dakota, and South Dakota are consistent with results from studies on effects from exposure to dioxin dioxin Aromatic compound, any of a group of contaminants produced in making herbicides (e.g., Agent Orange), disinfectants, and other agents. Their basic chemical structure consists of two benzene rings connected by a pair of oxygen atoms; when substituents on the rings are and dioxin-like compounds. Chlorophenoxy herbicides and chlorophenol production workers exposed to dioxin, based on estimates from job records and company exposure questionnaires, showed an increase in mortality from IHD and possibly diabetes (Vena et al. 1998). Likewise, studies of Operation Ranch Hand Operation Ranch Hand was a U.S. Military operation during part of the Vietnam War, lasting from 1962 until 1971. It involved spraying an estimated 19 million US gallons of defoliants over rural areas of South Vietnam in an attempt to deprive the Viet Cong of veterans showed an increase of mortality from circulatory system circulatory system, group of organs that transport blood and the substances it carries to and from all parts of the body. The circulatory system can be considered as composed of two parts: the systemic circulation, which serves the body as a whole except for the diseases (Michalek et al. 1998) and an increase in diabetes prevalence (Henriksen et al. 1997). This association between diabetes and serum dioxin levels in the Vietnam veterans This article is about the French band. For veterans of the Vietnam War, see Vietnam veteran. The Vietnam Veterans were a six-person French psychedelic group that released six records in the 1980s. The band was praised by many alternative music publications. has been defined as "limited and suggestive sug·ges·tive adj. 1. a. Tending to suggest; evocative: artifacts suggestive of an ancient society. b. " (Brown 2000). A dose response of IHD mortality in association with exposure to polychlorinated dibenzo-p-dioxins and dibenzofurans was observed in a German herbicide-producing plant (Flesch-Janys et al. 1995). Widespread exposure to dioxin from the Seveso, Italy, accident was associated with increased mortality from chronic IHD, cancer, and diabetes (Bertazzi et al. 2001). Increased hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. rates for IHD were observed among New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of State residents living near sites contaminated with persistent organic pollutants Persistent organic pollutants (POPs) are organic compounds that are resistant to environmental degradation through chemical, biological, and photolytic processes.[1] (Sergeev and Carpenter 2005). Increased mortality from diabetes and several cancers has been observed for pulp and paper mill workers (Axelson et al. 1998; Henneberger et al. 1989; Schwartz 1988; Wingren et al. 1991). Environmental factors are thought to play a role (Carpenter et al. 2002; Longnecker and Daniels 2001; Remillard and Bunce 2002). The increase in mortality from type 2 diabetes with increasing wheat acreage should be considered with caution. Estimated rates of diabetes mortality may be unreliable because of severe underreporting of the disease (CDC 2004b), in addition to usually not being listed as underlying cause of death (Geiss et al. 1995). To support the diabetes results, mortality in high- and low-wheat counties were compared for two additional diseases known to be associated with diabetes, namely, renal disease Renal disease Kidney disease. Mentioned in: Glycogen Storage Diseases hypertension High blood pressure Cardiovascular disease An abnormal ↑ systemic arterial pressure, corresponding to a systolic BP of > 160 mm Hg (ICD-9 580-589) and cerebrovascular disease cerebrovascular disease Neurology Any vascular disease affecting cerebral arteries–eg ASHD, diabetic vasculopathy, HTN, which may cause a CVA or TIA with neurologic sequelae–speech, vision, movement of variable duration. (ICD-9 430-438) (CDC 2004b; Harris 1995). Mortality from renal disease increased by 21% in high-wheat counties [risk ratio (RR) = 1.21; 95% CI, 1.12-1.31], whereas mortality from cerebrovascular disease did not show an effect (RR = 0.98; 95% CI = 0.94-1.03). These two disease groups were not further investigated. The seemingly seem·ing adj. Apparent; ostensible. n. Outward appearance; semblance. seem  ing·ly adv. contradictory outcomes of increasing mortality from
AMI and decreasing mortality from CAS in association with wheat acreage
agree with results of a study on cardiovascular mortality during
1987-1997 in Minnesota (Morrison et al. 2000). This study showed that in
the northwest region
The Northwest Region of Minnesota, where wheat is one of the major field crops, mortality from AMI was higher and mortality from CAS was lower compared with the other Minnesota regions, both in younger and older men and women. Assuming that CAS is a major risk factor for AMI, one could argue that among subjects susceptible to IHD, those more highly exposed died from AMI as underlying cause, resulting in fewer deaths being available for CAS, a case of competing mortality. Other interpretations are also worth considering. AMI often occurs in the absence of hyperlipidemia hyperlipidemia /hy·per·lip·id·emia/ (-lip?i-de´me-ah) elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc. . Recent studies have shown that high levels of C-reactive protein (C-RP C-RP Candidate-Rendezvous Point (PIM) ), an indicator of systemic systemic /sys·tem·ic/ (sis-tem´ik) pertaining to or affecting the body as a whole. sys·tem·ic adj. 1. Of or relating to a system. 2. inflammation, are associated with increased risk of AMI (as well as metabolic syndrome metabolic syndrome n. See syndrome X. Metabolic syndrome A group of risk factors for heart disease, diabetes, and stroke. and type 2 diabetes), independent of the level of CAS (Pradhan et al. 2001; Ridker et al. 2004). Although increased levels of C-RP and atherosclerosis may indicate distinct risk groups (Theuma and Fonseca 2003), elevated C-RP levels are thought to be the stronger predictor of future cardiovascular events and may be associated with plaque plaque (plak) 1. any patch or flat area. 2. a superficial, solid, elevated skin lesion. attachment plaques fragility and rupture rupture, in medicine: see hernia. (Aronow 2003; Hansson 2005; Ridker et al. 2002, 2004). If the increased mortality observed for AMI in the present study is indeed associated with increased C-RP levels, the observed decrease in mortality from CAS may now have an alternative interpretation. Considering that 2,4-D and MCPA have similar chemical structures as the hypolipidemic drug ctofibrate (2-[4-chlorophenoxy]-2-methylpropionic acid ethyl ethyl (ĕth`əl), CH3CH2, organic free radical or alkyl group derived from ethane by removing one hydrogen atom. ester) (Axelson et al. 1980) and that 2,4-D and MCPA, as well as clofibrate, have lipid-lowering effects in rats (Vainio et al. 1983), one might ask if the observed decrease in mortality from CAS could be caused by a lipid-lowering effect from environmental exposures to chlorophenoxy herbicides. Further studies will have to investigate this. Finally, differences among counties in determination of underlying cause of death as well as chance may have contributed to these findings. Conducting investigations of associations between environmental exposures and adverse human health effects is difficult for several reasons. Exposures are most likely widespread and low dose. A null comparison group may be unavailable (damage to the environment is global). Long lag periods between time of exposure and time of diagnosis of the chronic disease under study may present problems (McMichael 2002). Use of a multilevel mul·ti·lev·el adj. Having several levels: a multilevel parking garage. Adj. 1. multilevel - of a building having more than one level approach may be warranted (Pekkanen and Pearce 2001; Susser 1998). Evidence from studies at the molecular, individual, population, and/or ecosystem level needs to be combined to completely define the link between environmental exposure and health effects. This requires multidisciplinary mul·ti·dis·ci·pli·nar·y adj. Of, relating to, or making use of several disciplines at once: a multidisciplinary approach to teaching. studies and interdisciplinary in·ter·dis·ci·pli·nar·y adj. Of, relating to, or involving two or more academic disciplines that are usually considered distinct. interdisciplinary Adjective collaborations. Population (or ecologic) studies are fundamental as a first step in identifying a potential hazard and defining the key public health problem, because effects from exposures common throughout a study population can be uncovered only by comparison of populations (Pekkanen and Pearce 2001). Results from a single ecologic study can be easily misinterpreted and cannot establish causal inference (Morgenstern 1995). Individual risk factors cannot be accounted for in an ecologic study, because the focus is on the environment in which people live rather than on their personal lifestyles. Therefore, an ecologic study needs to be followed by an individual risk factor study based on hypotheses generated by the ecologic results, with adjustment for individual risk factors and confounders. An example in this study would be the potential confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor effect from smoking. Controlling for smoking usually has only a modest effect if risk estimates are high (Axelson and Steenland 1988). Although in the present study risk estimates for AMI are relatively low, there is no reason to assume that smoking rates per county increase with intensity of wheat farming. The fact that mortality from AMI increases with wheat percentage for both sexes, both younger and older subjects, and both 1979-1988 and 1989-1998 mortality cohorts suggests that the effects are associated with wheat agriculture. The present ecologic study as well as several previous studies used existing databases (Garry et al. 1996; Schreinemachers 2000, 2003; Schreinemachers et al. 1999). Comparison of regions at different levels of wheat farming provided the opportunity to observe adverse health effects in association with environmental exposures to chlorophenoxy herbicides and/or contaminants. Individual risk factor analysis could not have uncovered these associations easily. Results from the present study have generated hypotheses concerning the increase of AMI and the decrease of CAS in association with environmental, repeated (annually), low-dose exposures to chlorophenoxy herbicides and/or contaminants. Future, more definitive studies should include biomarkers such as serum levels of dibenzodioxins and dibenzofutans, levels of glycosylated hemoglobin gly·co·sy·lat·ed hemoglobin n. Any of four hemoglobin fractions that together account for less than 4 percent of the total hemoglobin in the blood. , lipid lipid Any of a diverse class of organic compounds, found in all living things, that are greasy and insoluble in water. One of the three large classes of substances in foods and living cells, lipids contain more than twice as much energy (calories) per unit of weight as the levels, white blood cell counts white blood cell count, n a diagnostic clinical laboratory test to determine the number and types of leukocytes present in a measured sample of blood. Overall the normal number of leukocytes ranges from 5000 to 10,000/mm3. and determination of C-RP. Subject-based studies should adjust for known individual risk factors for the diseases under study, such as obesity obesity, condition resulting from excessive storage of fat in the body. Obesity has been defined as a weight more than 20% above what is considered normal according to standard age, height, and weight tables, or by a complex formula known as the body mass index. , smoking, socioeconomic so·ci·o·ec·o·nom·ic adj. Of or involving both social and economic factors. socioeconomic Adjective of or involving economic and social factors Adj. 1. factors, and access to medical care. Molecular studies could investigate whether chlorophenoxy herbicides are synthetic ligands for peroxisome Peroxisome An intracellular organelle found in all eukaryotes except the archezoa (original lifeforms). In electron micrographs, peroxisomes appear round with a diameter of 0.1–1. proliferator activated activated a state of being more than usually active. In biological systems this is usually brought about by chemical or electrical means. Commonly said of pharmaceutical and chemical products. receptors (PPARs). Activation activation /ac·ti·va·tion/ (ak?ti-va´shun) 1. the act or process of rendering active. 2. the transformation of a proenzyme into an active enzyme by the action of a kinase or another enzyme. 3. of PPARs is the mechanism by which hypolipidemic fibrates induce hypolipidemia in humans (Clay et al. 2000; Vamecq and Latruffe 1999). In summary, this ecologic study is an example of how population studies can make valuable contributions to public health by identifying potential environmental hazards 'Environmental hazard' is a generic term for any situation or state of events which poses a threat to the surrounding environment. This term incorporates topics like pollution and Natural Hazards such as storms and earthquakes. . ADDENDUM addendum n. an addition to a completed written document. Most commonly this is a proposed change or explanation (such as a list of goods to be included) in a contract, or some point that has been subject of negotiation after the contract was originally proposed by The population estimates used for the analyses were obtained from CDC WONDER CDC WONDER CDC Wide-ranging ON-line Data for Epidemiologic Research and consist of Census intercensal estimates for 1971-1979 and 1981-1989, Census postcensal estimates for 1991-1999, and modified age-race-sex Census counts for the census years (1970, 1980, 1990, and 2000). These were the best population estimates available at the time of data collection (January-July 2003). Recent Census Bureau intercensal estimates for 1991-1999 showed that the postcensal estimates for 1991-1999 were too low. As a result, in the current study, the 1989-1998 population was underestimated by 0.6%. 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Nickels is a gambling coin game played with any desired denomination of coins. J, Hietanen E, Marniemi J. 1983. Hypolipidemia and peroxisome proliferation proliferation /pro·lif·er·a·tion/ (pro-lif?er-a´shun) the reproduction or multiplication of similar forms, especially of cells.prolif´erativeprolif´erous pro·lif·er·a·tion n. induced by phenoxyacetic acid herbicides in rats. Riochem Pharmacol 32:2775-2779. Vamecq J, Latruffe N. 1999. Medical significance of peroxisome proliferetor-activated receptors. Lancet 354:141-148. Vena J, Boffetta P, Becher H, Benn T, Bueno-de-Mesquita HB, Coggen D, et al. 1998. Exposure to dioxin and nonneoplastic mortality in the expanded IABC IABC International Association of Business Communicators IABC Indo-Americans for Better Community international cohort study A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design. In medicine, it is usually undertaken to obtain evidence to try to refute the existence of a suspected association between cause and disease; failure to refute of phenoxy herbicide and chlorophenol production workers and sprayers. Environ Health Perspect 106(suppl 2):645-653. Waite DT, Bailey P, Sproull JF, Quiring DV, Chau DF, Bailey J, et al. 2005. Atmospheric concentrations and dry and wet deposits of some herbicides currently used on the Canadian prairies The Canadian prairies is a large area of flat sedimentary land stretching throughout western Canada between the Canadian Shield in the east and the Canadian Rockies. The Canadian prairies – the portion of the Great Plains landform that supports various grasses and shrubs . Chemosphere chemosphere: see atmosphere. 58:693-703. Waite DT, Cessna AJ, Grover B, Kerr LA, Snihura AD. 2002. Environmental concentrations of agricultural herbicides: 2,4-D and triallate. J Environ Qual 31:129-144. Wingren G, Persson B, Thoren K, Axelson O. 1991. Mortality pattern among pulp and paper mill workers in Sweden: a case-referent study. Am J Ind Med 20:769-774. Address correspondence to D.M. Schreinemachers, Epidemiology and Biomarkers Branch, Human Studies Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency Environmental Protection Agency (EPA), independent agency of the U.S. government, with headquarters in Washington, D.C. It was established in 1970 to reduce and control air and water pollution, noise pollution, and radiation and to ensure the safe handling and , MD 58A, Research Triangle Park Research Triangle Park, research, business, medical, and educational complex situated in central North Carolina. It has an area of 6,900 acres (2,795 hectares) and is 8 × 2 mi (13 × 3 km) in size. Named for the triangle formed by Duke Univ. , NC 27711 USA. Telephone: (919) 966-5875. Fax: (919) 966-7584. E-mail: schreinemachers.dina@epa.gov I am grateful to the late O. Axelson for his support and for sharing his insight into the clofibrate-chlorophenoxy herbicide connection. I thank L. Birnbaum, J. Creason, B. Hilborn, P. Mendola, and especially V. Garry for their review of the manuscript. I also thank the anonymous EHP EHP abbr. 1. effective horsepower 2. electric horsepower reviewers for their useful comments. The research described in this article has been reviewed in accordance Accordance is Bible Study Software for Macintosh developed by OakTree Software, Inc.[] As well as a standalone program, it is the base software packaged by Zondervan in their Bible Study suites for Macintosh. with U.S. Environmental Protection Agency policy and approved for publication. Approval does not signify sig·ni·fy v. sig·ni·fied, sig·ni·fy·ing, sig·ni·fies v.tr. 1. To denote; mean. 2. To make known, as with a sign or word: signify one's intent. that the contents necessarily reflect the views and policies of the agency. The author declares she has no competing financial interests. Received 24 May 2005; accepted 6 October 2005.
Table 1. Characteristics [median (range)] of three groups of counties
based on tertiles of 1970-1979 percentage wheat acreage/county.
Average 1970-1979 percent
wheat acreage per growth
Characteristics Low
of county groups 0.95 (0.09-4.00)
No. of selected counties
Minnesota 32
Montana 1
North Dakota 0
South Dakota 18
Total 51
County land area, acres x [10.sup.6] 0.37 (0.22-1.92)
County cropland, acres x [10.sup.6] 0.24 (0.07-0.51)
1970-1979 percent dedicated land
Corn 21.74 (0.00-39.89)
Soybeans 4.16 (0.00-38.98)
Farm size, 1982 (acres) 303 (147-4,726)
Percent rural population, 1982 79.4 (53.1-100)
Percent farm population, 1982 25.1 (6.2-48.6)
Percent families below poverty level, 1979 12.0 (4.7-38.0)
Average annual population at risk
(percent [greater than or equal to] 65 years)
1979-1988
Male 447,124 (12.5)
Female 452,703 (16.5)
1989-1998
Male 479,003 (12.5)
Female 482,825 (16.6)
Average 1970-1979 percent
wheat acreage per growth
Characteristics Medium
of county groups 8.43 (4.04-14.32)
No. of selected counties
Minnesota 14
Montana 8
North Dakota 10
South Dakota 19
Total 51
County land area, acres x [10.sup.6] 0.71 (0.33-3.16)
County cropland, acres x [10.sup.6] 0.34 (0.15-0.71)
1970-1979 percent dedicated land
Corn 0.93 (0.00-31.98)
Soybeans 0.00 (0.00-28.87)
Farm size, 1982 (acres) 1,276 (233-5,154)
Percent rural population, 1982 100 (52.2-100)
Percent farm population, 1982 30.5 (11.9-64.8)
Percent families below poverty level, 1979 14.9 (7.5-34.3)
Average annual population at risk
(percent [greater than or equal to] 65 years)
1979-1988
Male 220,924 (15.1)
Female 220,884 (18.8)
1989-1998
Male 209,192 (16.3)
Female 210,840 (20.6)
Average 1970-1979 percent
wheat acreage per growth
Characteristics High
of county groups 22.91 (14.52-35.47)
No. of selected counties
Minnesota 10
Montana 6
North Dakota 30
South Dakota 4
Total 50
County land area, acres x [10.sup.6] 0.71 (0.28-2.55)
County cropland, acres x [10.sup.6] 0.50 (0.18-1.24)
1970-1979 percent dedicated land
Corn 0.06 (0.00-21.59)
Soybeans 0.01 (0.00-10.25)
Farm size, 1982 (acres) 984 (453-3,661)
Percent rural population, 1982 100 (50.7-100)
Percent farm population, 1982 30.2 (13.9-51.1)
Percent families below poverty level, 1979 12.7 (6.6-25.7)
Average annual population at risk
(percent [greater than or equal to] 65 years)
1979-1988
Male 172,776 (16.2)
Female 171,621 (20.0)
1989-1998
Male 149,245 (18.1)
Female 150,107 (22.9)
Table 2. Mortality rates of IHD, AMI, CAS, and diabetes mellitus for
all ages in rural, agricultural counties of Minnesota, Montana, North
Dakota, and South Dakots, compared with U.S. rates.
Selected counties
(n = 152)
Rate/
100,000
Underlying cause (ICD-9) Year of death No. Crude
IHD (410-414.9)
Male 1979-1988 28,599 340.1
1989-1998 21,763 259.9
Female 1979-1988 19,651 232.5
1989-1998 16,821 199.4
AMI (410)
Male 1979-1988 18,338 218.1
1989-1998 12,493 149.2
Female 1979-1988 10,996 130.1
1989-1998 8,663 102.7
CAS (414.0)
Male 1979-1988 7,318 87.0
1989-1998 5,032 60.1
Female 1979-1988 6,831 80.8
1989-1998 4,821 57.1
Diabetes mellitus (250)
Male 1979-1988 1,235 14.7
1989-1998 1,888 22.5
Female 1979-1988 1,453 17.2
1989-1998 2,148 25.5
Person-years at risk
Male 1979-1988 8,408,234
1989-1998 8,374,404
Female 1979-1988 8,452,082
1989-1998 8,437,721
Selected
counties
(n = 152)
Rate/
100,000
U.S. (white)
Age rate/100,000
Underlying cause (ICD-9) Year of death adjusted age adjusted
IHD (410-414.9)
Male 1979-1988 250.7 272.2
1989-1998 176.4 189.1
Female 1979-1988 110.6 138.2
1989-1998 79.8 100.9
AMI (410)
Male 1979-1988 165.0 150.6
1989-1998 104.0 92.5
Female 1979-1988 66.9 68.8
1989-1998 44.3 47.3
CAS (414.0)
Male 1979-1988 59.9 88.1
1989-1998 38.9 50.1
Female 1979-1988 33.5 54.8
1989-1998 20.2 31.6
Diabetes mellitus (250)
Male 1979-1988 10.9 12.7
1989-1998 15.4 17.0
Female 1979-1988 9.3 11.6
1989-1998 12.0 14.0
Person-years at risk
Male 1979-1988
1989-1998
Female 1979-1988
1989-1998
Table 3. Age-standardized mortality rates/100,000, ratios, and 95% CIs
for IHD, AMI, CAS, and diabetes mellitus, in low-, medium-, and
high-wheat counties.
Underlying cause
of death (ICD-9) Age (years) Sex Year of death
IHD (410-414.9)
25- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1979-1988
1989-1998
25-64 Male 1979-1988
1989-1998
Female 1979-1988
1989-1998
65- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1979-1988
1989-1998
AMI (410)
25- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1975-1988
1989-1998
25-64 Male 1979-1988
1989-1998
Female 1975-1988
1989-1998
65- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1979-1988
1989-1998
CAS (414.0)
25- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1979-1988
1989-1998
25-64 Male 1979-1988
1989-1998
Female 1979-1988
1989-1998
65- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1979-1988
1989-1998
Diabetes
mellitus
(250.0-250.9)
45- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1979-1988
1989-1998
45-64 Male 1979-1988
1989-1998
Female 1979-1988
1989-1998
65- [greater than or Male 1979-1988
equal to] 85 1989-1998
Female 1979-1988
1989-1998
Underlying cause Low wheat
of death (ICD-9) Age (years) Sex rate
IHD (410-414.9)
25- [greater than or Male 458.00
equal to] 85 312.03
Female 205.03
143.93
25-64 Male 148.30
89.26
Female 36.89
22.27
65- [greater than or Male 1844.07
equal to] 85 1309.05
Female 957.57
688.44
AMI (410)
25- [greater than or Male 285.31
equal to] 85 173.68
Female 117.25
75.24
25-64 Male 104.21
53.11
Female 25.54
13.46
65- [greater than or Male 1095.81
equal to] 85 713.32
Female 527.69
351.77
CAS (414.0)
25- [greater than or Male 122.72
equal to] 85 77.44
Female 67.54
39.18
25-64 Male 28.64
22.92
Female 7.55
4.76
65- [greater than or Male 543.74
equal to] 85 321.46
Female 335.99
193.20
Diabetes
mellitus
(250.0-250.9)
45- [greater than or Male 32.60
equal to] 85 44.79
Female 28.75
35.83
45-64 Male 13.15
15.00
Female 8.85
9.87
65- [greater than or Male 73.13
equal to] 85 106.86
Female 70.22
89.94
Medium wheat
Underlying cause
of death (ICD-9) Age (years) Sex Rate
IHD (410-414.9)
25- [greater than or Male 463.55
equal to] 85 331.23
Female 196.47
148.76
25-64 Male 158.30
99.75
Female 34.30
26.91
65- [greater than or Male 1829.70
equal to] 85 1367.23
Female 922.24
694.10
AMI (410)
25- [greater than or Male 315.87
equal to] 85 202.03
Female 123.06
85.27
25-64 Male 121.89
71.20
Female 26.06
18.13
65- [greater than or Male 1184.03
equal to] 85 787.56
Female 557.16
385.76
CAS (414.0)
25- [greater than or Male 102.34
equal to] 85 69.49
Female 56.16
37.56
25-64 Male 20.52
14.87
Female 4.80
4.53
65- [greater than or Male 468.55
equal to] 85 313.94
Female 286.01
185.38
Diabetes
mellitus
(250.0-250.9)
45- [greater than or Male NA
equal to] 85 NA
Female NA
NA
45-64 Male NA
NA
Female NA
NA
65- [greater than or Male NA
equal to] 85 NA
Female NA
NA
Medium wheat
Underlying cause
of death (ICD-9) Age (years) Sex SRR (95% CI)
IHD (410-414.9)
25- [greater than or Male 1.01 (0.98-1.04)
equal to] 85 1.06 (1.03-1.10)
Female 0.96 (0.92-0.99)
1.03 (0.99-1.08)
25-64 Male 1.07 (1.00-1.14)
1.18 (1.03-1.21)
Female 0.93 (0.82-1.06)
1.21 (1.04-1.41)
65- [greater than or Male 0.99 (0.96-1.02)
equal to] 85 1.04 (1.01-1.08)
Female 0.96 (0.93-1.00)
1.01 (0.97-1.05)
AMI (410)
25- [greater than or Male 1.11 (1.07-1.15)
equal to] 85 1.16 (1.11-1.21)
Female 1.05 (1.00-1.10)
1.13 (1.07-1.20)
25-64 Male 1.17 (1.09-1.26)
1.34 (1.22-1.48)
Female 1.02 (0.88-1.19)
1.35 (1.12-1.63)
65- [greater than or Male 1.08 (1.04-1.12)
equal to] 85 1.10 (1.05-1.16)
Female 1.06 (1.01-1.11)
1.10 (1.04-1.16)
CAS (414.0)
25- [greater than or Male 0.83 (0.79-0.88)
equal to] 85 0.90 (0.84-0.96)
Female 0.83 (0.78-0.88)
0.96 (0.89-1.03)
25-64 Male 0.72 (0.61-0.84)
0.65 (0.54-0.78)
Female 0.64 (0.46-0.87)
0.95 (0.67-1.36)
65- [greater than or Male 0.86 (0.81-0.91)
equal to] 85 0.98 (0.91-1.05)
Female 0.85 (0.80-0.91)
0.96 (0.89-1.03)
Diabetes
mellitus
(250.0-250.9)
45- [greater than or Male NA
equal to] 85 NA
Female NA
NA
45-64 Male NA
NA
Female NA
NA
65- [greater than or Male NA
equal to] 85 NA
Female NA
NA
High wheat
Underlying cause
of death (ICD-9) Age (years) Sex Rate
IHD (410-414.9)
25- [greater than or Male 475.52
equal to] 85 353.28
Female 213.27
154.43
25-64 Male 155.32
109.90
Female 35.56
29.56
65- [greater than or Male 1908.59
equal to] 85 1442.56
Female 1008.60
713.32
AMI (410)
25- [greater than or Male 333.99
equal to] 85 225.77
Female 138.32
93.91
25-64 Male 126.04
82.16
Female 28.58
22.08
65- [greater than or Male 1264.69
equal to] 85 868.54
Female 629.51
415.35
CAS (414.0)
25- [greater than or Male 96.19
equal to] 85 61.05
Female 56.89
32.72
25-64 Male 16.00
12.27
Female 4.44
3.99
65- [greater than or Male 455.07
equal to] 85 279.38
Female 291.62
161.30
Diabetes
mellitus
(250.0-250.9)
45- [greater than or Male 36.28
equal to] 85 55.73
Female 30.19
42.03
45-64 Male 13.35
18.77
Female 8.70
11.95
65- [greater than or Male 84.07
equal to] 85 132.72
Female 74.98
104.72
High wheat
Underlying cause
of death (ICD-9) Age (years) Sex SRR (95% CI)
IHD (410-414.9)
25- [greater than or Male 1.04 (1.01-1.07)
equal to] 85 1.13 (1.09-1.17)
Female 1.04 (1.00-1.08)
1.07 (1.03-1.12)
25-64 Male 1.05 (0.98-1.12)
1.23 (1.13-1.34)
Female 0.96 (0.84-1.10)
1.33 (1.13-1.56)
65- [greater than or Male 1.03 (1.00-1.07)
equal to] 85 1.10 (1.06-1.14)
Female 1.05 (1.01-1.09)
1.04 (0 99-1.08)
AMI (410)
25- [greater than or Male 1.17 (1.13-1.21)
equal to] 85 1.30 (1.24-1.36)
Female 1.18 (1.12-1.24)
1.25 (1.18-1.32)
25-64 Male 1.21 (1.12-1.31)
1.55 (1.40-1.71)
Female 1.12 (0.96-1.31)
1.64 (1.35-1.99)
65- [greater than or Male 1.15 (1.11-1.20)
equal to] 85 1.22 (1.16-1.28)
Female 1.19 (1.13-1.25)
1.18 (1.11,1.25)
CAS (414.0)
25- [greater than or Male 0.78 (0.74-0.83)
equal to] 85 0.79 (0.73-0.85)
Female 0.84 (0.79-0.90)
0.84 (0.77-0.91)
25-64 Male 0.56 (0.46-0.68)
0.54 (0.43-0.67)
Female 0.59 (0.41-0.84)
0.84 (0.55-1.27)
65- [greater than or Male 0.84 (0.79-0.89)
equal to] 85 0.87 (0.80-0.94)
Female 0.87 (0.81-0.93)
0.83 (0.77-0.91)
Diabetes
mellitus
(250.0-250.9)
45- [greater than or Male 1.11 (0.98-1.26)
equal to] 85 1.24 (1.13-1.37)
Female 1.05 (0.93-1.18)
1.17 (1.06-1.30)
45-64 Male 1.01 (0.76-1.35)
1.25 (0.97-1.62)
Female 0.98 (0.70-1.39)
1.21 (0.88-1.66)
65- [greater than or Male 1.15 (1.01-1.31)
equal to] 85 1.24 (1.12-1.38)
Female 1.07 (0.95-1.21)
1.16 (1.05-1.29)
NA, not applicable.
Table 4. Poisson regression comparing high-wheat (HW) and medium-wheat
(MW) counties with low-wheat counties (LW), with adjustment for
mortality cohort, sex, age, and poverty index.
Model no., disease (ICD-9) Age (years) RR (95% CI)
Combined states, combined
age groups
1. IHD (410-414.9) 25- [greater than or
LW equal to] 85 1.00
MW 1.01 (0.98-1.04)
HW 1.08 (1.04-1.12)
2. AMI (410) 25- [greater than or
LW equal to] 85 1.00
MW 1.09 (1.04-1.14)
HW 1.20 (1.14-1.26)
3. CAS (414.0) 25- [greater than or
LW equal to] 85 1.00
MW 0.90 (0.85-0.96)
HW 0.89 (0.83-0.96)
4. Diabetes mellitus 45- [greater than or
(250.0-250.9) equal to] 85
LW 1.00
HW 1.16 (1.08-1.24)
Combined states, separate
age groups
5. AMI (410) 25-64
LW 1.00
MW 1.21 (1.14-1.29)
HW 1.31 (1.22-1.39)
6. AMI (410) 65- [greater than or
LW equal to] 85 1.00
MW 1.05 (1.00-1.11)
HW 1.16 (1.10-1.22)
Separate states, combined
age groups
AMI (410) 25- [greater than or
7. Minnesota, LW equal to] 85 1.00
Minnesota, HW 1.12 (1.06-1.19)
8. Montana, LW 1.00
Montana, HW 1.06 (0.91-1.23)
9. North Dakota, LW 1.00
North Dakota, HW 1.16 (1.08-1.24)
10. South Dakota, LW 1.00
South Dakota, HW 1.07 (1.00-1.15)
Model no., disease (ICD-9) No. (Male/female)
Combined states, combined
age groups
1. IHD (410-414.9)
LW 42,444 (24,139/18,305)
MW 23,780 (14,112/9,668)
HW 20,592 (12,099/8,493)
2. AMI (410)
LW 23,359 (14,016/9,343)
MW 14,293 (8,925/5,368)
HW 12,828 (7,884/4,944)
3. CAS (414.0)
LW 12,732 (6,535/6,197)
MW 6,300 (3,271/3,029)
HW 4,967 (2,541/2,426)
4. Diabetes mellitus
(250.0-250.9)
LW 4,251 (1,920/2,331)
HW 2,271 (1,083/1,188)
Combined states, separate
age groups
5. AMI (410)
LW 3,705 (2,952/753)
MW 2,378 (1,924/454)
HW 2,018 (1,612/406)
6. AMI (410)
LW 19,654 (11,064/8,590)
MW 11,915 (7,001/4,914)
HW 10,810 (6,272/4,538)
Separate states, combined
age groups
AMI (410)
7. Minnesota, LW 16,337 (9,813/6,524)
Minnesota, HW 14,586 (8,978/5,608)
8. Montana, LW 939 (616/323)
Montana, HW 1,013 (616/397)
9. North Dakota, LW 3,282 (2,055/1,227)
North Dakota, HW 4,947 (3,162/1,785)
10. South Dakota, LW 4,757 (2,797/1,960)
South Dakota, HW 4,619 (2,788/1,831)
RR values are adjusted for sex (male vs. female), age ([greater than or
equal to] 65 vs. < 65), mortality cohort (1989-1998 vs. 1979-1988), and
poverty index (1980 median, [greater than or equal to] 13.15 vs.
< 13.15). The exposure variable, percentage of a county's land area
dedicated to wheat farming, is based on tertiles with cut-points 4.04
and 14.50 (models 1-3, 5, 6) or the median with cut-point 8.43 (model
4). Median wheat percentage values for the individual states are as
follows: Minnesota, 3.19 (model 7); Montana, 9.87 (model 8); North
Dakota, 19.93 (model 9); and South Dakota, 5.29 (model 10). Median for
individual states' poverty index are Minnesota, 11.00; Montana, 11.40;
North Dakota, 13.20; and South Dakota, 19.30.
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