Transitions of cardiovascular risk from adolescence to young adulthood—The Bogalusa heart study: I. Effects of alterations in lifestyle

J Chron Dis Vol. 39, No. 2, pp. 81-90, 1986 Printed in Great Britain.All rightsreserved

0021-9681/86 $3.00+ 0.00 Copyrightic: 1986PergamonPressLtd

TRANSITIONS OF CARDIOVASCULAR RISK FROM ADOLESCENCE TO YOUNG ADULTHOOD-THE BOGALUSA HEART STUDY: I. EFFECTS OF ALTERATIONS IN LIFESTYLE JANET B. CROFT,’ THEDA A. FOSTER,’ FRANK C. PARKER,~ JAMES L. CRESANTA,~ SAUNDRA MAcD. HUNTER,~ LARRY S. WEBBER,’ SATHANUR R. SRINIVASAN~ and GERALD S. BERENSON’ Departments of ‘Medicine, 2Biometry and Genetics, ‘Psychiatry, 4Public Health and Preventive Medicine, SFamily Medicine and 6Biochemistry, Louisiana State University Medical Center, New Orleans, LA 70112-2822, U.S.A. (Received

in revised form

27 June 1985)

Abstract-Adolescence

and young adulthood represents a transition period for biologic and lifestyle characteristics. In a preliminary investigation of young adults (ages 18-20 years), the Bogalusa Heart Study documented patterns of alcohol, tobacco, and oral contraceptive use, as well as changes in education, occupational, marital and parenting status. Such behaviors accelerate the cardiovascular disease process and may differentially influence risk factor patterns of race and sex groups. Adverse levels of systolic blood pressure and a-lipoprotein cholesterol were more frequent in married vs single men; elevated triglyceride levels were more frequent in married vs single whites. However adverse levels of p- and a-lipoprotein cholesterol were more frequent in nonparents than in parents. Cigarette smoking and oral contraceptive use were independently related to elevated j-lipoprotein cholesterol and decreased a-lipoprotein cholesterol levels of young white women. Alcohol consumption was highest among white males, with 32% reporting daily consumption of the equivalent of two or more beers or one mixed drink. Alcohol consumption was negatively correlated with blood pressure in white males and positively correlated with a-lipoprotein cholesterol in black males. Since such lifestyle factors are related to physiologic risk factors that result in heart disease and adult cardiovascular morbidity and mortality in the older ages, early targeting during adolescence and young adulthood is important.

INTRODUCTION

ATHEROSCLEROSISbegins early in life [ 1,2], with cardiovascular

[CV] risk factor variables becoming apparent in childhood and adolescence [2-61. Adolescence and young adulthood also represent important transition periods involving not only biologic, hormonal, and vascular changes [7-lo], but also developmental changes in behavior and lifestyle [l 1, 121. The immediate post-high school years, ages 18-25, are marked by developmental shifts such as changes in alcohol and tobacco use, eating patterns, marriage, parenting, employment and moving from dependence on family to autonomy. This work documents changes in lifestyle and behavior of young adults. Interactions of sociological factors such as marriage with CV risk factors are investigated. In addition, the pathophysiologic effects of oral contraceptive use and cigarette smoking on serum lipids and lipoproteins in young women, and the influence in men of smoking and alcohol consumption on blood pressure and serum lipoproteins are examined. Correspondence and reprint requests: Dr Gerald S. Berenson, M.D., Specialized Center of ResearchArteriosclerosis, L.S.U. Medical Center, 1542 Tulane Avenue. New Orleans. LA 70112-2822. U.S.A. This study was supported by funds from the National Heart, Lung and Blood Institute of the United States Public Health Service, Specialized Center of Research-Arteriosclerosis (SCOR-A) HL15103. 81

a2

JANETB. CROFTet

al.

METHODS

The Bogalusa Post-High School Study is designed to examine all young adults born since 1 January 1959, who previously had been examined in the Bogalusa Heart Study as children and adolescents. The purpose of the study is to follow changes in CV risk factor levels in these young adults and to explore influences on CV risk in the transition period of adolescence and young adulthood. A survey was conducted on the eligible young adult population in 1979-80 (three birth cohorts, ages 18-20 years). Demographic characteristics of the population and the geographic area are described elsewhere [2,6, 13, 141. Registry

In order to maintain a population base for subsequent surveys of these young adults and later age cohorts, a Post High School Registry was established. Working with the cooperation of the school board and high school, the Bogalusa staff annually distributes permission-to-follow-up forms to all individuals in the age cohort of interest. Basic demographic data (name, address, sex, date of birth, date of high school graduation, etc.) are collected. Each consenting young adult also gives written permission for his parent/guardian, a designated friend or any of several public agencies (Internal Revenue Service, Department of Public Safety, etc.) to provide a current address and phone number. This demographic formation is entered onto the computer-based registry. Thereafter, a comprehensive follow-up form is used annually to update demographic data and information on education, marital status, parenting and employment. Of the several approaches used for follow-up (return requested postcard, registered letter, home visit), annual phone calls were the most effective. The three cohorts examined in 1979-80 consisted of those born from 1 January 1959 to 30 June 1962. Table 1 presents the 1979-80 registry status of the 1659 young adults (ages 18-20) who were originally examined as children in the Bogalusa Heart Study. Many of this cohort (26%) are included on the registry who had moved from the community prior to beginning this study and could not be reidentified or located. The 1136 (69%) who had given consent to continued follow-up are defined as the eligible population for 1979-80. Approximately one-third of the participants had not completed registry forms at the time of examination; however, information concerning that time period was collected in the registry update the following year. Recruitment

Examination of current zip codes showed that of the eligible adult 1979-80 population, 92% white males, 86% white females, 93% black males, and 93% black females still resided in Washington Parish (County) in 1980. Overall, 15% of the eligible 1979-80 population were currently enrolled in college and 16% in the local high school and/or vocational-technical school. Young adults living in the area were examined on weekdays or weekends in the Bogalusa office. Those living away from the community or attending college were examined on weekends or holidays. Additionally, a mobile team conducted examinations at campus health clinics for the young adults attending colleges in Louisiana and Mississippi or at local senior high and vocational-technical schools. Examination procedures

Trained examiners followed written protocols for the examination which included the same procedures as those for school children [2,4, 13-161: fasting serum lipids and lipoproteins, glucose and hemoglobin; anthropometric measurements (height, weight, triceps skinfold thickness, arm circumference and length); and blood pressure (BP) measurements. A modified Rose questionnaire on health history and habits [17] was administered. In standardized interviews young adults were questioned about cigarette smoking (history, number of cigarettes/day, years of smoking), other tobacco use and alcohol consumption (history, frequency and amounts of beer, wine, and whiskey usually

83

Lifestyleand CV Risk TABLE i.&GlSTRY AND PARTICIPATION STATUSOF YOUNG ADULTS(18-20 YEARS) PREWOUSLY EXAMWED IN LONGITUDINAL CARDIOVASCULAR RISK FACTOR SURVEY, B~GALUSA HEART STUDY, 1979-80 N Original examined Deceased Refusal

pediatric

to registry

Nonrespondent before Consent

follow-up

(moved

registry

follow-up

in

from

follow-up

1979-80 consents)

(27.4%

1659

%

loo.0

IO

0.6

75

4.5

community

established)

to registry

Examined

population

438

26.4

1136

68.5

311

18.7

of

consumed in a week or in the one week prior to examination). Females were interviewed to determine menstrual and gynecological history as well as oral contraceptive use. Responses concerning cigarette smoking were compared to adolescent data previously collected in 1976-1977 during the second cross-sectional survey of the Bogalusa Heart Study. At that time this population answered a health habits questionnaire concerning tobacco use and history [l&20], socio-environmental influences [21] and influence of health-related beliefs and attitudes on smoking behavior. Trained interviewers used alcoholic beverage models and conversion tables to assure reliable assessment of alcohol consumption. The conversion tables assume that one 12 ounce beer equals 355.2 ml of 4% alcohol, one 6 ounce glass of wine equals 177.6ml of 12% alcohol and one mixed drink containing 2 ounces of (80 proof) alcohol equals 59.2 ml of 40% alcohol. The formula for weekly dietary alcohol consumption (ml/week) = beers x 14.2 + glasses of wine x 21.3 + mixed drinks x 23.7. Daily consumption of dietary alcohol was the weekly dietary alcohol consumption divided by seven. Participation The survey examined 311 (27%) of the eligible young adults, age 18-20 years (Table 1). Of the eligible population (those who had given consent to adult followups) 95 (25%) white males, 141 (36%) white females, 34 (18%) black males, and 41 (23%) black females were examined. One basis for the apparent low participation is that the Post High School Study was not developed until 4 years after the initial pediatric survey was begun in Bogalusa and the registry includes all potential adolescents from the onset of the Bogalusa Heart Study. To ascertain whether nonresponse in the Post High School screening introduced a selection bias into the results, levels of selected pediatric risk factor variables from the 1973-74 observations on these cohorts were compared. There were no significant (p < 0.05) physiological differences in anthropometric measurements, serum lipids and lipoproteins, or blood pressure between participants and nonparticipants. Among black males originally examined in the Bogalusa Heart Study, participation decreased for each age cohort, with rates of 18, 13 and 5% for 18, 19 and 20 year olds, respectively (p < 0.01). A similar relationship was noted among black girls, with participation in 23% of 18 year olds, 17% of 19 year olds and 9% of 20 year olds (p < 0.05). Demographic data from the registry were compared with participation. Among those providing registry information, several demographic characteristics related significantly to participation. Among white males, more 18-year-old nonparticipants were current students (p < 0.05) and more 20-year-old nonparticipants were employed (p < 0.05) as compared to participants. Among white females, more nonparticipants were married (p < O.OOl),and 20-year-old nonparticipants had received more advanced education (p < 0.005) and were less likely to be parish residents (p < 0.01). More black female nonparticipants than participants were mothers (p < 0.05). There was no relationship between marital status and either age or residency in any race, sex, or participation group. Statistical methods Interrelationships between CV risk factors, race, sex and age have been extensively studied in Bogalusa and other populations of adolescents [2,4-6]. These observations,

JANET B. CROFT et al.

84

TABLE 2. ADVERSE CARDIOVASCULAR RISK FACTOR LEVELS OF YOUNG ADULTS, AGES 18-20, B~CALUSA HEART STUDY, 1979-80

Cardiovascular

Risk Factor

Serum cholesterol (2 220 mg/dl) P-Lipoprotein cholesterol* (a 140 mg/dl) z-Lipoprotein cholesterol* (< 30 mg/dl) Triglycerides* (2 140 mg/dl) Systolic blood ~ressure (2 130 mmHe) diastolic blood’ pressure’ (2 85 mmHgi *Fasting

White males (N = 95) N (%) 4 7 I4 I2 9 8

(4) (8) (18) (14) (9) isi

White females (N = 141) N (%) 12 17 I2 I2 3 7

(9) (13) (9) (9) (2) i5j

Black males (N =34) N (%) I

2

Black females (N =41) N I%) ~

I

(6) (3)

:

:, 9 4

<‘) (26) il2j

: 0 3

I

(2) (21) (3) (5) (7)

TO&l (N = 311) N 1%)

28 26 21 22

(IO) (9) (71 i7j

only.

therefore, do not attempt to explore differences in these CV risk factors between race and sex groups; instead we chose to examine the impact of lifestyle behavior on these parameters within each race and sex group. Race and sex specific distributions are presented for each major lifestyle factor (marriage, parenting, employment, education and use of tobacco, oral contraceptives, and alcohol). For each variable, race and sex-specific analyses of the interrelationships with systolic and diastolic BP, serum total cholesterol, triglycerides and p-, pre#- and a-lipoprotein cholesterol levels are examined. Statistical analysis includes correlation coefficients, frequency distributions, and analysis of variance. All analyses were performed using Statistical Analysis System (SAS User’s Guide, 1982, Cary, NC). RESULTS

Cardiovascular risk factors

Table 2 lists adverse cardiovascular risk factor levels of blood pressure, serum lipids and lipoproteins for each race and sex group based on arbitrary cutpoints. About 18% white males had a-lipoprotein cholesterol levels less than 30 mg/dl and 14% had elevated triglyceride (140 mg/dl or more) levels. High B-lipoprotein cholesterol levels (140 mg/dl or more) occurred in 13% white females and 21% black females. In 34 black males 26% had systolic blood pressures above 130 mmHg and 12% had diastolic blood pressures above 85 mmHg. Marriage

Registry information concerning marital status, parenting, employment, and education of the 311 participants in 1979-80 is presented in Table 3. Overall 76 (24%) had been married, but 6 (8%) of the married group were already divorced, and 4 (5%) separated from their spouses. Systolic blood pressures of 130 mmHg or greater were found in 23% married and 11% unmarried men. Among whites 16% married and 11% unmarried young adults had a-lipoprotein cholesterol less than 30 mg/dl. Triglyceride of 140 mg/dl or more were noted in 16% married as compared to 10% unmarried whites. Beta-lipoprotein cholesterol levels of 140 mg/dl or more were found in 12% married and 16% unmarried women. Parenting

Parenthood was reported by 10% white males, 16% white females, 18% black males and 12% black females (Table 3). Levels of p-lipoprotein cholesterol of 140 mg/dl or more were found in 8% parents, 13% nonparents, while 8% parents, 11% nonparents had a -lipoprotein cholesterol levels less than 30 mg/dl. Employment

Current employment is demonstrated in Table 3 with 65% young adults categorized as unemployed. This category includes those who reported unemployment (26%) as well as students who did not report an occupation (39%). Overall, 6% were working students, 11% were employed in white collar jobs, 12% in blue collar jobs, 5% in the military, and

.

Lifestyle TABLI: 3. DEMOGRAPHICCHARACTERISTICSOF YOUNG ADLXTS FACTOR

Characteristic Marital status Never married Currently married Dworced Separated Number

SURWY.

BY

RACE

AND

and CV Risk

(I

85

B-20 YEARS) EXAMINED BOCALUSA HEART

SEX.

IN A LONG~TUDNAL STUDY.

CARD,•

“ASC”LAR

RISK

1979-80

White males (N = 95) N (%)

White females (N = 141) N (%)

Black males (N = 34) N (%)

Black females (N = 41) N (%)

Total (N=31l) N (%)

71 21 2 I

(75) (22) (2) (1)

106 29 3 3

(75) (21) (2) (2)

27 7 0 0

(79) (21)

31 9 I 0

(76) (22) (2)

235 66 6 4

(76) (21) (2) (11

85 9

(90) (9)

II9 I9 3 0

(84) (14) (2)

28 5 I 0

(82) (15) (3)

36 3 I I

(88)

268 36 6 I

(86) (II) (2) (1)

(18)

IO

(29)

5

(9) (40) (8) (6) (2) (6) (11)

102 I I 0 7 3

(35) (3) (3)

1: 3 I I 6 3

1121 ii2j (42) (7) (2)

63 18 122 19 15 4 37 33

(20) (6) (39) (6) (5) (1) (12) (II)

(7) (18) (35) (39) (1)

1: I4 4 0

31 66 105 104 5

(IO) (21) (34) (33) (2)

of children

0 I ,

i

I

3 or more

0

(1)

Occupation Unemployed Unemployed wife Non-working student Working student Military Service worker Blue collar White collar

23 0 36 4 5 0 I5 I2

(24)

(16) (13)

25 I3 57 II 8 3 9 I5

Education < I2 years High school student High school graduate College student College graduate

II I6 31 34 3

(11) (17) (33) (36) (3)

:: 49 55 2

1% were 13 white coded as lipids or

(38) (4) (5)

G) (9) (15) (32) (41) (12)

(7) (2) (2)

ii (15) (7)

(12) I: II II 0

(34) (27) (27)

service workers. No women reported “housewife” as an occupation; therefore, women and 5 black women who were married and reported unemployment are unemployed wife. Employment status was not related to blood pressure, serum lipoproteins.

Education

Overall 214 (69%) had graduated from high school (Table 3). Fewer blacks were high school graduates (53%) than whites (74%), but more blacks were still enrolled in high school (33 vs 17%). More whites reported attending college or having received one or more years of education following high school graduation than did blacks (40 vs 20%). Among 29 black males educational status showed a positive correlation (r = 0.38, p < 0.05) with /I-lipoprotein cholesterol. There were no interrelationships in the other race and sex groups. Tobacco use

Cigarette, cigar and pipe smoking were higher among males than females (Table 4). Current cigarette smoking was highest among white males (36%) followed by 28% white females, 24% black males and 12% black females. Almost 76% black females reported never having smoked. There were 29% black males, 25% white females, 17% white males and 12% black females who used to smoke but quit. Smoking behavior of 5 years or more was reported by 13% white males, 10% white females and 3% black males. At least 10 cigarettes per day (one-half pack) were smoked by 30% white males, 23% white females, 15% black males and 10% black females. White women who did not use oral contraceptives showed negative correlations of number of cigarettes per day with diastolic blood pressure (r = -0.21, p < 0.05) and z-lipoprotein cholesterol (Y = -0.24, p < 0.05). White males also showed a negative correlation between number of cigarettes smoked per day and a-lipoprotein cholesterol (r = -0.26, p < 0.05) and positive correlations with triglycerides (Y = 0.28, p < 0.05) and pre-P-lipoprotein cholesterol (Y = 0.25, p < 0.05). Cigarette smoking behavior of adolescents was collected in 1976-77 [ 18-211. Three years later, 211 were re-examined in the 1979-80 study of young adults. Of this population, 91

86

JANET B. CROFT et al.

TABLE

4. TOBACCOAND ALCOHOL “SE OF YOUNG ADULTS (18-20 YEARS), BY RACE AND SEX. BOGALUSAHEART STUDY. 1979-80

Use of item

White males (N = 95) (%)

White females (N = 141) (%)

Black males (N = 34) (%)

Black females (N = 41) (O/b)

Smokes cigarettes Smoked 5 years or more Never smoked Smoked but quit Smokes cigars Smokes pipe

35.8

27.7

23.5

12.2

12.6 47.4 16.8 6.3 3.2

9.9 47.5 24.8 I .4 0.7

2.9 47.1 29.4 I I.8

75.6 12.1

Dietary alcohol (ml/day) consumption* 30

10.4 21.9 27.1 21.9 18.7

10.6 48.2 30.5 8.5 2.1

II.8 35.3 32.3 8.8 II.8

41.5 34.1 22.0 2.4

‘Dietary alcohol equivalents: I2 oz. beer = 14.2 ml; 6 oz. wine = 21.3 ml; 2 oz. alcohol = 23.7 ml

initially reported never smoking, 59 reported quitting, and 61 were currently smoking. Figure 1 illustrates the changes in cigarette smoking behavior of each race and sex group. Among young adults who initially reported never smoking, approx. 80% maintained that behavior. Among those who had tried cigarettes 3 years earlier but quit, 50% black males, 41% white females, 38% white males and 25% black females resumed smoking. Among previous 1976-77 smokers who were re-examined in 1979-80, 50% black females, 40% black males, 30% white females and 18% white males reported that they no longer smoked cigarettes. Oral contraceptives

Oral contraceptives (OC) were used by 35 (25%) white females and 15 (37%) black females. A greater frequency of adverse levels for the following CV risk factor variables was noted among OC-users as compared to nonusers: serum cholesterol 2220 mg/dl

CIGARETTE

SMOKING

BY RACE,

BEHAVIOR

OF YOUNG ADULTS AFTER THREE YEARS

SEX AND INITIAL

SMOKING

BOGALUSA HEART STUDY, 1076-77. INITIAL SMOKING

CATEGORY 1879-80 H

While rno1e5 N ~65

.

White females

BEHAVIOR N=96

NEVER 100

1

OUITTER

SMOKED

SMOKER Block moles N -24

0

s’ack N: femo’es 26

60-

NW

1 Mafntolned

smoker

CURRENT FIG. 1. Three

Resumed

Malntotned

outt

smoking

SMOKING

BEHAVIOR

year follow up of cigarette smoking behavior of young adults, ages 18-20 years, by race, sex and 197&77 smoking category-the Bogalusa Heart Study, 1976-77, 1979-80. New smokers in this age group were about equal for each race and gender group. White children reported greatest use of cigarettes and black girls were least likely to become or remain smokers.

Lifestyle and CV Risk

87

(17 vs 6%) /I-lipoprotein cholesterol z 140 mg/dl [28 vs 8%, p < 0.02, Fisher’s exact test (2-tail)], E-lipoprotein cholesterol < 30 mg/dl (13 vs 8%) and triglycerides 3 140 mg/dl [22 vs 5%, p < 0.01, Fisher’s exact test (2-tail)]. Alcohol use

The usual daily consumption of dietary alcohol is demonstrated in Table 4 with 68% white males, 41% white females, 53% black males and 24% black females who reported drinking 10 ml dietary alcohol or more per day (equivalent of more than half a 12-ounce beer per day). The equivalent of a mixed drink (2 ounces 80-proof alcohol) per day or more was consumed by 32% white males, 9% white females, 18% black males and 2% black females. A negative correlation was noted among white males between daily dietary alcohol consumption and systolic (Y = -0.23, p < 0.05) and diastolic (r = -0.23, p < 0.05) blood pressures and a positive correlation with cigarettes smoked per day (1. = 0.36, p < 0.0005). Alcohol intake was positively associated with a-lipoprotein cholesterol in black males (r = 0.43, p < 0.05). DISCUSSION

In this survey, young adults were examined for CV disease risk factors. Lifestyle indicators such as educational achievement, marital and parenting status, occupation, and use of alcohol, tobacco, and oral contraceptives were also obtained to determine any emerging interrelationships with blood pressure, serum lipids and lipoprotein cholesterol. Since only 27% of the eligible population were examined (as shown in Table l), this sample may be biased by small numbers with respect to differences in employment, educational level and marital status. For example, the 20-year-old white males who were employed were less likely to be examined than were unemployed males. Further studies on a larger number of young adults are needed to define the subtle effects of sociological factors occurring at this age. Lifestyle, an individual’s daily pattern of living, has a significant impact on overall health status and general population morbidity and mortality [22], especially with respect to CV disease [23-261. Some important lifestyle indicators that influence physical and mental health include education [27], occupation and income [28], marital and parenting status [2993 11, and health practices [32-341. Health practices that are associated with CV disease risk factors include weight maintenance [34], physical activity [35], cigarette smoking [36] and alcohol consumption [37,38]. In the Framingham 8-year study of 45-65 year-old white women there were no significant differences in CV risk factor levels between women working outside the home and housewives; however, married mothers who were clerical workers showed coronary heart disease rates twice that of comparable housewives and women in other positions, suggesting that the time demands of working and raising a family increases CV risk in women [39]. Similar results were noted in men having three or more children as compared to men with no children [40]. In the Bogalusa study of 18-20 year olds, greater frequencies of married men showed adverse levels of systolic blood pressure and a-lipoprotein and married whites showed greater frequencies of high triglycerides than unmarried adults. However, adverse levels of /I- and cc-lipoprotein cholesterol were more frequent in single women and nonparents than in married women or parents suggesting that family life may have a beneficial effect at this young age. Current OC use is associated with adverse levels of lipids and lipoproteins, especially in females who smoke [20,36,41-431. Bogalusa white 18-20-year-old OC-users had altered levels for serum cholesterol, triglycerides, B-lipoprotein cholesterol and c(-lipoprotein cholesterol more frequently than nonusers, similar to earlier findings in Bogalusa adolescents [20]. Negative health habits such as cigarette smoking are clearly associated with development of CV disease and cancer [36], with mortality ratios proportional to the duration of the smoking habit. Nationally, cigarette consumption among male children and adults appears

88

JANET B. CROFT et al.

to be decreasing, although this is not true for women [44]. Similarly the national rate of initiation of smoking among young men is declining but not among young women [44]. This trend is also seen in the Bogalusa population. The 197677 survey of this population showed that among adolescents a greater percent of boys, especially white males, began smoking at an early age but also began quitting early in adolescence. White girls tend to begin smoking later, but are more likely to remain habitual smokers [18, 191. In the young adult study of 1979-80 there appears to be a decline in cigarette smoking in all race and sex groups with less of an increase among whites. This population demonstrated inverse relationships of cigarettes per day to levels of blood pressure and cr-lipoprotein cholesterol and positive correlations with triglycerides and pre-/?-lipoprotein cholesterol. These results are comparable to those reported for this group as adolescents [20]. Alcohol consumption in the Bogalusa population was highest among white males followed by black males, white females and, finally, black females. More than 20% of the young white adult men admitted to consuming the equivalent of two or more beers per day and 30% the equivalent of one mixed drink per day. These findings are similar to those reflected nationally. Studies of American adolescent drinking behavior show that twothirds of 18-year-old females and more than three-fourths of males reported some alcohol use in the past month [45]. In a study of 190,000 U.S. Army soldiers (18-24 years), the mean age of initial alcohol experience was 13.1 years with 25% reporting initial alcohol consumption by age 10 years [46]. Compared to nonusers, a higher percentage of abusers of alcohol and illegal drugs started alcohol, cigarette and coffee consumption at age 12 or younger [46]. Among males and white females in the Bogalusa population, there is also a significant positive association between number of cigarettes smoked per day and daily alcohol consumption. These data show important associations between alcohol use and CV risk factors. White males showed a negative correlation with blood pressure. Black males showed a positive correlation with cc-lipoprotein cholesterol. Other studies have noted that moderate alcohol consumers appear to have more favorable levels of CV risk factors and lower morbidity and mortality than nondrinkers or heavy drinkers [38,47-501. A strong linear relationship between alcohol consumption and blood pressure has been noted in men over age 50, suggesting a delayed cumulative alcohol dose-effect [51]. Jessor’s research shows onset of alcohol use and cigarette smoking is a normal feature of adolescent development and also relates to other transitional behaviors such as marihuana use and initial sexual intercourse [52]. The pattern of adolescent behavior tends toward higher values for independence, social criticism, tolerance of transgression, peer rather than parental orientation and approval of and involvement in problem behaviors while attaching lower values to conventionality, religiosity and achievement [52]. One critical developmental juncture point in reorganization of behaviour occurs when the young adult leaves the family and gains more control over his lifestyle [53]. This is not always a smooth and harmonious process. As young adults leave home, resocialization occurs. Peers and institutions in college or the military teach new beliefs, values and norms, many of which are related to health practices. Some habits formed earlier already have become addictive, such as cigarette smoking. Others, such as eating patterns and food choices, may dramatically change. Whereas the adolescent puts energy into “trying on” adult behaviors within limited economic resources, the young adult may adopt a lifestyle not possible while under parental supervision and even greater economic constraints. Post high school observations on lifestyle factors are extremely important, since such environmental factors in older adults are related to risk factors that result in atherosclerosis and adult CV morbidity and mortality. The Bogalusa study shows that such risk factor and lifestyle interrelationships are just beginning to emerge in adolescence and young adulthood. Further investigations of this age cohort as they mature may help to bridge the gap between observations of pediatric populations, such as Bogalusa and Muscatine [6], and those of adult populations, such as Framingham [40]. Although primary prevention targeting childhood is being encouraged, it is apparent that social and economic forces in young adulthood can alter the impact of such programs on CV risk.

Lifestyle and CV Risk

89

Consequently, understanding lifestyles in adolescence and young adulthood will provide useful information for developing rational approaches to CV health promotion in children, adolescents and young adults. AcknoM,/edgemenrs-The Bogalusa Heart Study represents the collaborative efforts of many people whose cooperation is gratefully acknowledged. We expecially thank the Bogalusa staff, Mrs Imogene Talley, Mrs Bettye Seal, Mrs Linda Smith, and the children and young adults of Bogalusa without whom this study YouId not be possible. We also thank MS Rosanne P. Farris for alcohol models and conversion tables and Drs Caroline V. Blonde and Ralph R. Frerichs for preliminary design and implementation of the Post High School Study.

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