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14 Mortality among Seventh-Day Adventists in Relation to Dietary Habits and Lifestyle 1

Roland L. Phillips and David A. Snowdon

Loma Linda University, School of Medicine, Center for Health Promotion, Loma Linda, CA 92350

Downloaded by YORK UNIV on June 3, 2018 | https://pubs.acs.org Publication Date: June 18, 1986 | doi: 10.1021/bk-1986-0312.ch014

This report summarizes 21 years of mortality follow-up for 25,000 California members of the Seventh-day Adventist church. Compared to the general population, Adventists have an exceptionally low risk of fatal lung cancer which is clearly accounted for by their lack of cigarette smoking. They also have a marked reduction in risk of fatal large bowel cancer, coronary disease, stroke, diabetes and nontraffic accidents. Compared to Adventists who heavily use meat the vegetarian Adventists have a substantially lower risk of fatal coronary disease, fatal diabetes and death from any cause, especially among men. Among Adventist men who use few animal products (meat, milk, cheese, eggs) the risk of fatal prostate cancer is one third that of Adventist men who heavily use such products. Moderate use of coffee is associated with an increased risk of fatal large bowel cancer among both sexes and an increased risk of coronary death and all-cause deaths among males. Since the amount of meat and coffee used by Adventists tends to reflect their overall adherence to the prudent practices advocated by the Adventist church, these findings suggest that the Adventist lifestyle may delay premature death from several major causes of death. Seventh-day Adventists have been o f f i c i a l l y organized as a church for about 120 years. Within a few years after t h e i r organization, Adventist leaders began to advocate p a r t i c u l a r habits and practices that were f e l t to promote better health. Smoking and drinking of alcoholic beverages soon became proscriptions which are c a r e f u l l y adhered to by the vast majority of Adventists (99 per cent nonsmokers, 90 per cent nondrinkers). The Adventist church also recommends (but does not require) i t s members to avoid c e r t a i n dietary items such as meat, poultry, f i s h , coffee, tea, other 1

Current address: University of Minnesota, Division of Epidemiology, Minneapolis, M N 55455. 0097-6156/86/0312-0162$06.00/0 © 1986 American Chemical Society

Ory; Plant Proteins: Applications, Biological Effects, and Chemistry ACS Symposium Series; American Chemical Society: Washington, DC, 1986.


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c a f f e i n e - c o n t a i n i n g b e v e r a g e s , r i c h and h i g h l y r e f i n e d f o o d s , and hot condiments and s p i c e s . These recommendations a c c o u n t f o r the f a c t t h a t c u r r e n t l y about o n e - f o u r t h o f A d v e n t i s t s a r e l i f e t i m e l a c t o - o v o - v e g e t a r i a n s , o n e - f o u r t h have adopted the v e g e t a r i a n d i e t sometime in l i f e ( u s u a l l y s h o r t l y a f t e r j o i n i n g the c h u r c h ) , and o n e - h a l f o f the A d v e n t i s t s c u r r e n t l y f o l l o w a n o n v e g e t a r i a n diet. T h i s v a r i a t i o n r e s u l t s in a p o p u l a t i o n w i t h much w i d e r v a r i a t i o n in exposure to meat than one c o u l d f i n d in a t y p i c a l sample o f the general population. A d v e n t i s t s who chose t o use l i t t l e o r no meat a l s o tend to f o l l o w many o t h e r n u t r i t i o n a l p r a c t i c e s t h a t a r e b e l i e v e d to promote h e a l t h . Thus, wide v a r i a t i o n in many d i e t a r y e x p o s u r e s , in a p o p u l a t i o n which is r e l a t i v e l y homogeneous in many o t h e r c h a r a c t e r i s t i c s r e l e v a n t t o c a n c e r r i s k , p r o v i d e s an i d e a l s e t t i n g to t e s t d i e t a r y h y p o t h e s e s . S e r i o u s i n t e r e s t in the h e a l t h s t a t u s o f A d v e n t i s t s i n i t i a l l y a r o s e in the l a t e 1950's as p a r t o f a surge of r e s e a r c h e f f o r t t o i n v e s t i g a t e the h e a l t h e f f e c t s o f t o b a c c o use. A d v e n t i s t s p r o v i d e an o p p o r t u n i t y t o e v a l u a t e the r i s k o f s m o k i n g - r e l a t e d d i s e a s e s among a group who r e p o r t e d l y a b s t a i n from b o t h t o b a c c o and a l c o h o l . A d v e n t i s t s a r e o f p a r t i c u l a r i n t e r e s t as r e s e a r c h s u b j e c t s because former smokers or heavy meat u s e r s u s u a l l y dropped t h e i r h a b i t because o f r e l i g i o u s r e a s o n s , r a t h e r t h a n i l l n e s s , and a s i z a b l e p r o p o r t i o n o f A d v e n t i s t s n e v e r i n i t i a t e d smoking o r meat use. B r i e f Overview o f Study Methods In 1960 i n v e s t i g a t o r s a t Loma L i n d a U n i v e r s i t y c o l l e c t e d b a s e l i n e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e d a t a on demographic, s o c i o l o g i e , m e d i c a l , d i e t a r y and l i f e s t y l e c h a r a c t e r i s t i c s from 25,000 C a l i f o r n i a A d v e n t i s t s age 35 and o v e r . These s u b j e c t s were c a r e f u l l y f o l l o w e d t h r o u g h 1965 and d e a t h c e r t i f i c a t e s were o b t a i n e d f o r a l l d e a t h s so t h a t causes o f d e a t h c o u l d be t a b u l a t e d . We have r e c e n t l y completed the t a s k o f e x t e n d i n g the f o l l o w - u p o f t h e s e 25,000 s u b j e c t s t h r o u g h 1980 v i a a c o m p u t e r - a s s i s t e d r e c o r d l i n k a g e p r o c e d u r e w i t h the C a l i f o r n i a death c e r t i f i c a t e f i l e . D u r i n g t h i s 21-year f o l l o w - u p p e r i o d 7,250 s u b j e c t s have d i e d . U t i l i z i n g t h i s updated m o r t a l i t y d a t a , t h i s r e p o r t w i l l r e c a p i t u l a t e and summarize the key f i n d i n g s which have been r e p o r t e d d u r i n g the 25 y e a r s s i n c e the study began (1-15). M o r t a l i t y among A d v e n t i s t s V e r s u s the G e n e r a l

Population

E a r l y in the f o l l o w - u p p e r i o d i t became c l e a r t h a t A d v e n t i s t s have a v e r y low r i s k o f l u n g c a n c e r (1) and o t h e r f a t a l d i s e a s e s s t r o n g l y r e l a t e d to use o f c i g a r e t t e s o r a l c o h o l (mouth c a n c e r , esophagus cancer, r e s p i r a t o r y disease, l i v e r c i r r h o s i s , e t c . ) . T a b l e I shows t h a t the r i s k o f f a t a l l u n g c a n c e r among A d v e n t i s t s is 25% o f the r i s k among g e n e r a l p o p u l a t i o n s u b j e c t s o f comparable age. The s t a n d a r d i z e d m o r t a l i t y r a t i o used on t h i s t a b l e is a c o n v e n i e n t s t a t i s t i c t o use in comparing m o r t a l i t y r a t e s o f any p a r t i c u l a r group ( A d v e n t i s t s in t h i s c a s e ) t o the g e n e r a l p o p u l a t i o n w h i l e t a k i n g i n t o a c c o u n t the f a c t t h a t the d i s t r i b u t i o n o f age (the p r i n c i p l e d e t e r m i n a n t o f d e a t h ) may not be comparable between the two g r o u p s . A s t a n d a r d i z e d m o r t a l i t y r a t i o o f 100 f o r any g i v e n cause o f d e a t h would i n d i c a t e t h a t the r i s k o f A d v e n t i s t s d y i n g from t h a t cause is


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Table I Age-Standardized Mortality Ratios f o r Selected Causes of Death Among 25,000 White C a l i f o r n i a Adventists, 1960-1980


CAUSE of DEATH

STANDARDIZED MORTALITY RATIO (100 χ obs/exp) Male Female Both

59*

75 175 182 94 723

306.5 358.0 219.3 126.7 1227.6

44* 48* 39*

43* 48* 40*

2460 1035 116

5744.6 2154.2 288.7

107 47* 46*

113 35* 80

110 40* 57*

119 123 44

108.4 306.9 77.0

46*

51*

49*

7250

14756.4

LUNG CANCER LARGE BOWEL CANCER BREAST CANCER PROSTATE CANCER ALL OTHER CANCER

—

CORONARY DISEASE STROKE DIABETES TRAFFIC ACCIDENTS OTHER ACCIDENTS SUICIDE ALL CAUSES

NUMBER of DEATHS (both sexes) _| Observed Expected

16* 55*

47* 46* 83*

25* 49*

74* 58*

—

—

59*

42* 47* 45*

—

The p r o b a b i l i t y that the mortality d i f f e r e n t i a l between Adventists and a l l U.S. whites is accounted f o r by chance alone is under O.05. The number of deaths expected i f white C a l i f o r n i a Adventists (age 35 or over) had the same concurrent r i s k of dying (within each of 26 sex-age groups) as a l l whites in the United States. equal to persons of the same age and sex in the general population. Twelve years ago, we were intrigued by the data on c e r t a i n causes of death other than lung cancer (Table I ) . For several of these causes (large bowel cancer, breast cancer, prostate cancer, diabetes) the r i s k among Adventists is s u b s t a n t i a l l y below the general population even though they are unrelated to cigarette and alcohol use. This suggests that aspects of the Adventist l i f e s t y l e other than abstinence from tobacco and alcohol may account f o r t h e i r low r i s k . We are now in the twelth year of a t o t a l l y new study which is primarily designed to i d e n t i f y the s p e c i f i c components of the Adventist's l i f e s t y l e which may reduce t h e i r r i s k of acquiring these diseases. This ongoing study d i f f e r s from the previous mortality study in three major ways: (1) the study population is considerably larger, (2) the baseline data on l i f e s t y l e is more detailed, and (3) the outcome of interest is newly acquired disease events rather than only f a t a l disease events. The other s p e c i f i c causes of death which are shown on Table I (coronary disease, stroke, accidents and suicide) are known to be related to alcohol or tobacco use. However, for f a t a l coronary disease, which is the major k i l l e r in t h i s country, the r i s k among



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Adventists is substantially below the r i s k in comparable subjects in the general population who have never smoked (8). In view of the abstinence from alcohol in Adventists, i t is especially surprising to note that their r i s k of f a t a l t r a f f i c accidents is about the same as the r i s k in the general population, although other accidents appear to be substantially lower among Adventists. This may p a r t i a l l y r e f l e c t the fact that the cause of a f a t a l t r a f f i c accident is often outside of the v i c t i m ' s c o n t r o l , while other accidents usually r e f l e c t the v i c t i m ' s own behavior. It is conceivable that the r e l a t i v e l y high r i s k of t r a f f i c accidents among Adventists may p a r t i a l l y be accounted for by their low use of caffeinated beverages. Furthermore, the one study that has examined the driving habits of Adventists found that they tend to accrue somewhat more t r a f f i c c i t a t i o n s than comparable peers in the general population (16). The r e l a t i v e l y low r i s k of suicide among Adventist men raises the poss i b i l i t y that the Adventist way of l i f e may provide effective ways of coping with the extreme stresses of l i f e . However, the fact that Adventist women are not c l e a r l y at lower r i s k of suicide does not support this concept, p a r t i c u l a r l y in view of the tendency of women to take their r e l i g i o n more seriously than men. The bottom l i n e of Table I shows that the age-standardized r i s k of dying from any cause among Adventists is one-half of the r i s k in the general population. This does not mean that Adventists are immortal in some mystical way. With the exception of a few causes of death which are caused almost e n t i r e l y by tobacco or alcohol (lung cancer, l i v e r c i r r h o s i s , e t c . ) , the proportion of deaths attributed to each of the major causes of death in the U.S. is e s s e n t i a l l y equal among Adventists and U.S. whites. Adventists simply die l a t e r . This r e l a t i v e delay in the age at which Adventists succumb to most f a t a l diseases results in a lower age-standardized death rate and a longer l i f e expectancy. Compared to their general population peers, l i f e expectancy among Adventists who reach age 35 is 6 years longer for men and 4 years longer for women (3). Our ongoing study w i l l enable us to determine whether this increased l i f e expectancy among Adventists is due to a delay in acquiring l i f e threatening diseases or to a tendency to l i v e longer with t h e i r diseases. The l a t t e r p o s s i b i l i t y is not a desirable s i t u a t i o n . Longer l i f e is only desirable i f the quality of l i f e is also extended. L i f e s t y l e Versus Selection Although comparisons between Adventists and the general population are i n t e r e s t i n g , considerable caution is warranted in drawing inferences from such comparisons. Proponents of the Adventist l i f e s t y l e tend to use such data to extol the virtues of the Adventist l i f e s t y l e which "obviously" accounts for their favorable mortality rates. It is important to note that over 50% of the Adventist subjects in this study are adult converts to the church and such converts are c l e a r l y not a random sample of the general population. In f a c t , i t is reasonable to assume that adults in the general population who choose to j o i n the Adventist church are a select group of rather unique and unusual people whose r i s k of acquiring or dying from any given disease may have been d i s t i n c t l y different from the general population at the time they converted to Adventism. If this were true, the primary explanation for their low r i s k may not be the 7


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166

l i f e s t y l e they adopted a f t e r j o i n i n g the c h u r c h , but r a t h e r the n o n l i f e s t y l e t r a i t s which c h a r a c t e r i z e p e r s o n s who choose to c o n v e r t t o Adventism. However, i t is p o s s i b l e t h a t some c o n v e r t s to Adventism were l i v i n g a l i f e s t y l e somewhat comparable t o A d v e n t i s t s p r i o r t o j o i n i n g the c h u r c h . F u r t h e r m o r e , m o r t a l i t y d a t a f o r the g e n e r a l p o p u l a t i o n is based on a l l p e r s o n s in the p o p u l a t i o n . Thus, g e n e r a l p o p u l a t i o n m o r t a l i t y d a t a i n c l u d e s d e a t h s among s u b j e c t s who were i n s t i t u t i o n a l i z e d o r i l l a t the onset o f the s t u d y , whereas such s u b j e c t s in the A d v e n t i s t p o p u l a t i o n would not be l i k e l y t o complete a q u e s t i o n n a i r e which is the p r e r e q u i s i t e f o r i n c l u s i o n in the Adventist m o r t a l i t y data. Even the l i f e t i m e A d v e n t i s t s a r e not f r e e from s e l e c t i o n b i a s . Through no c h o i c e o f t h e i r own they were endowed w i t h m u l t i p l e c h a r a c t e r i s t i c s from t h e i r p a r e n t s who were l i k e l y c o n v e r t s t o the c h u r c h . C l e a r l y , the g e n e r a l p o p u l a t i o n is not a v e r y a p p r o p r i a t e comparison group f o r A d v e n t i s t s . Thus, o n l y v e r y l i m i t e d i n f e r e n c e s can be d e r i v e d from such c o m p a r i s o n s . M o r t a l i t y and

L i f e s t y l e V a r i a t i o n s Within

Adventists

Because o f these u n a v o i d a b l e problems in comparing A d v e n t i s t s w i t h the g e n e r a l p o p u l a t i o n we have adopted the p o i n t o f v i e w t h a t much more can be l e a r n e d about the r e l a t i o n s h i p between l i f e s t y l e and r i s k of d i s e a s e by comparing A d v e n t i s t s w i t h A d v e n t i s t s . The v a r y i n g degrees o f c o m p l i a n c e which A d v e n t i s t s e x h i b i t toward the h e a l t h recommendations o f the c h u r c h p r o d u c e s a s i z a b l e v a r i a t i o n in l i f e s t y l e patterns. In f a c t , f o r many h a b i t s the v a r i a t i o n among A d v e n t i s t s is much g r e a t e r than one c o u l d f i n d in the g e n e r a l population. For example, a p p r o x i m a t e l y h a l f o f the A d v e n t i s t s in t h i s study a r e l a c t o - o v o - v e g e t a r i a n s and 20% use meat f o u r or more days per week. Thus, A d v e n t i s t s p r o v i d e a r i c h r e s o u r c e f o r i n v e s t i g a t i n g the h e a l t h e f f e c t s o f l i f e s t y l e v a r i a t i o n s w i t h o u t the need f o r an e x t e r n a l comparison group which would l i k e l y c o n f u s e the picture. The remainder o f t h i s r e p o r t w i l l f o c u s p r i m a r i l y on comparisons between A d v e n t i s t s who have v a r y i n g d e g r e e s o f adherence to the c h u r c h ' s recommendation a g a i n s t the use o f meat and c o f f e e . Meat Use. On T a b l e I I , meat use r e f e r s t o the combined use o f b o t h meat and p o u l t r y because they were u n f o r t u n a t e l y combined in a s i n g l e q u e s t i o n on the q u e s t i o n n a i r e . T a b l e I I u t i l i z e s r e l a t i v e r i s k as an e a s i l y i n t e r p e t a b l e means o f r e l a t i n g meat use t o the r i s k o f d y i n g of s e v e r a l common d i s e a s e s w h i c h a r e o f t e n c o n s i d e r e d t o be l i f e s t y l e r e l a t e d . S u b j e c t s who consume no meat a r e used as the r e f e r e n c e c a t e gory and thus t h e i r r e l a t i v e r i s k is a r b i t r a r i l y s e t t o one. The r e l a t i v e r i s k among s u b j e c t s in o t h e r c a t e g o r i e s o f meat consumption r e l a t e s d i r e c t l y t o the r e f e r e n c e c a t e g o r y . For example a r e l a t i v e r i s k o f 2.0 f o r a c c i d e n t a l d e a t h among s u b j e c t s who consume meat 4 or more days p e r week ( h y p o t h e t i c a l d a t a not shown on t a b l e ) would i n d i c a t e t h a t the r i s k o f a f a t a l a c c i d e n t among heavy meat u s e r s is t w i c e t h a t o f s u b j e c t s who use no meat. A r e l a t i v e r i s k o f O.5 would i n d i c a t e t h a t the r i s k in the comparison group is one h a l f t h a t o f the r e f e r e n c e group. A l l r e l a t i v e r i s k s a r e a g e - s t a n d a r d i z e d which e s s e n t i a l l y e l i m i n a t e s the p o s s i b i l i t y t h a t the r i s k d i f f e r e n t i a l between the comparison and r e f e r e n c e group c o u l d be due t o a d i f f e r e n t age d i s t r i b u t i o n in the two g r o u p s . I f the measured r i s k between the comparison and r e f e r e n c e group were s o l e l y due t o a markedly o l d e r


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Table II Relationship of Meat Consumption to the Age-Standardized Relative Risk of Dying from the Indicated Cause Among 25,000 C a l i f o r n i a Adventists, 1960-1980

RIS Κ R E L AΤ I V E (in reference to nonusers) NUMBER Meat No Meat OF Meat 1-3 days 4+ days DEATHS per week per week (2) (3) (3) (2) (1) (1)

CAUSE of DEATH

SEX

LARGE BOWEL CANCER BREAST CANCER PROSTATE CANCER

Β F M

1.0 1.0 1.0

1.4 1.2 1.2

O.9 1.2 1.5

CORONARY DISEASE

M F

1.0* 1.0*

1.4 1.2

1.7 1.2

607 917

306 188 395 240

STROKE

M F

1.0 1.0

1.3 1.2

1.2 O.9

199 425

90 168

37 83

DIABETES

M F

1.0* 1.0*

1.3 1.2

3.6 2.1

18 39

9 18

13 21

ALL CAUSES

M F

1.0* 1.0

1.2 1.1

1.5 1.1

77 92 57

44 53 25

18 41 15

1583 719 453 2577 1089 695

The p r o b a b i l i t y that chance alone accounts for the progressive increase in r e l a t i v e r i s k across meat use categories is under O.05 (under O.001 for a l l causes). ^Meat refers to combined use of meat and p o u l t r y . There were no subjects who used f i s h without also reporting use of meat and poultry. age d i s t r i b u t i o n in the comparison group the "raw" (nonstandardized) r e l a t i v e r i s k in the comparison group would be substantially greater than one, while the age-standardized r e l a t i v e r i s k would be exactly equal to one. The "no meat" category includes 1049 subjects who report occasional meat use (less than once per week). They were combined with subjects who indicated t h e i r use of meat as "0" days per week. A l l subjects in the occasional use category took the effort to write a note to this effect on t h e i r questionnaire. We suspect many more subjects who r e a l l y belong in the occasional use category simply recorded t h e i r use as "0" because i t approximates their use closer than "1 day/wk". The most surprising observations on Table II are the lack of a clear relationship between meat use and r i s k of f a t a l cancers of the large bowel and breast. Evidence from several other studies suggests that a d i r e c t positive association should be evident (10). However, data from a growing number of recent studies are not consistent with an association between meat use and r i s k of large bowel cancer or breast cancer (17-19). Meat use is also unrelated to a l l types of cancer combined. Ory; Plant Proteins: Applications, Biological Effects, and Chemistry ACS Symposium Series; American Chemical Society: Washington, DC, 1986.


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PLANT PROTEINS

An a s s o c i a t i o n between meat use and f a t a l p r o s t a t e c a n c e r is e v i d e n t in T a b l e I I , a l t h o u g h i t is not s t a t i s t i c a l l y s i g n i f i c a n t . A d d i t i o n a l a n a l y s e s (not shown on t a b l e ) show a s i m i l a r degree o f a s s o c i a t i o n between use o f o t h e r a n i m a l p r o d u c t s (eggs, m i l k , cheese) and f a t a l p r o s t a t e c a n c e r . I f use o f a l l f o u r a n i m a l p r o d u c t s a r e combined i n t o an index w h i c h r e f l e c t s t h e i r combined use, a v e r y c l e a r r e l a t i o n s h i p emerges ( T a b l e I I I ) . Thus, i t appears t h a t heavy use o f a l l f o u r a n i m a l p r o d u c t s is a s s o c i a t e d w i t h a t h r e e - f o l d i n c r e a s e in r i s k o f f a t a l p r o s t a t e c a n c e r . In males the r i s k o f f a t a l c o r o n a r y d i s e a s e shows a s u b s t a n t i a l s t e p w i s e i n c r e a s e w i t h i n c r e a s i n g meat use. A l t h o u g h the a s s o c i a t i o n between meat use and f a t a l c o r o n a r y d i s e a s e is s t a t i s t i c a l l y s i g n i f i c a n t in f e m a l e s , the degree o f i n c r e a s e d r i s k w i t h heavy meat use is r a t h e r s m a l l . The p a t t e r n is r a t h e r s i m i l a r f o r b o t h males and f e m a l e s when a l l c a u s e s o f d e a t h a r e c o n s i d e r e d t o g e t h e r . However, t h e s e r e l a t i o n s h i p s w i t h meat use a r e somewhat s t r o n g e r among younger males under age 65 ( T a b l e I V ) . In t h i s age group o f males, the r i s k o f f a t a l c o r o n a r y d i s e a s e among heavy meat u s e r s is i n c r e a s e d by a f a c t o r o f 2.5. F u r t h e r m o r e , heavy meat use is a s s o c i a t e d w i t h a 40% i n c r e a s e in the r i s k o f d y i n g o f n o n c o r o n a r y c a u s e s and a 70% i n c r e a s e f o r a l l c a u s e s . Thus, c a u s e s o f d e a t h o t h e r than c o r o n a r y d i s e a s e s u b s t a n t i a l l y c o n t r i b u t e t o t h i s i n c r e a s e d r i s k of dying. The r a t h e r s t r o n g r e l a t i o n s h i p between meat use and f a t a l d i a b e t e s was o n l y r e c e n t l y d i s c o v e r e d , and t o our knowledge t h i s r e l a t i o n s h i p has not been r e p o r t e d by o t h e r i n v e s t i g a t o r s . S i n c e most p e o p l e w i t h d i a b e t e s do not d i e from t h e i r d i s e a s e , m o r t a l i t y d a t a is not the p r e f e r a b l e type o f d a t a t o use in i n v e s t i g a t i n g a p o s s i b l e c a u s a t i v e l i n k between d i a b e t e s and meat u s e . However, the r e l a t i o n s h i p is f a i r l y s t r o n g and shows a d o s e - r e s p o n s e p a t t e r n f o r b o t h males and f e m a l e s d e s p i t e a v e r y l i m i t e d number o f d i a b e t i c deaths. There is a c l e a r need f o r f u r t h e r s t u d i e s t o e v a l u a t e the r e l a t i o n s h i p o f meat and o t h e r d i e t a r y h a b i t s t o the f r e q u e n c y o f d i a b e t e s u t i l i z i n g more d i r e c t methods o f m e a s u r i n g d i a b e t e s r i s k . C o f f e e Use. T a b l e V f o c u s e s on the r e l a t i o n s h i p o f c o f f e e use t o the same s i x c a u s e s o f d e a t h c o n s i d e r e d on p r e v i o u s t a b l e s . A p p r o x i m a t e l y 70% o f the A d v e n t i s t s in t h i s s t u d y use no c o f f e e . However, 17% d r i n k two or more cups o f c o f f e e per day and 10% l i m i t t h e i r i n t a k e t o one cup p e r day. The "no c o f f e e " c a t e g o r y i n c l u d e s 362 s u b j e c t s who r e p o r t o c c a s i o n a l c o f f e e use ( l e s s t h a n one cup per day). They were combined w i t h s u b j e c t s who i n d i c a t e d t h e i r c o f f e e use as "0" cups per day. A l l s u b j e c t s in the o c c a s i o n a l use c a t e g o r y took the e f f o r t t o w r i t e a note t o t h i s e f f e c t on t h e i r questionnaire. We s u s p e c t many more s u b j e c t s who r e a l l y b e l o n g in the o c c a s i o n a l use c a t e g o r y s i m p l y r e c o r d e d t h e i r use as "0" cups p e r day because i t a p p r o x i m a t e s t h e i r use c l o s e r than "1 cup p e r day". U n f o r t u n a t e l y , the q u e s t i o n n a i r e d i d not d i s t i n g u i s h between c a f f e i n a t e d v e r s u s d e c a f f e i n a t e d c o f f e e o r i n s t a n t v e r s u s brewed coffee. P o s i t i v e a s s o c i a t i o n s w i t h c o f f e e use a r e seen f o r f a t a l l a r g e bowel c a n c e r in b o t h s e x e s , f a t a l c o r o n a r y d i s e a s e in males o n l y , and p o s s i b l y f o r a l l c a u s e s o f d e a t h in males o n l y . Both sexes were combined f o r l a r g e bowel c a n c e r because the degree o f a s s o c i a t i o n was e s s e n t i a l l y e q u i v a l e n t when examined s e p a r a t e l y f o r




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Table I I I R e l a t i o n s h i p o f A n i m a l P r o d u c t Use t o t h e A g e - S t a n d a r d i z e d R e l a t i v e r i s k o f f a t a l P r o s t a t e Cancer Among 9000 C a l i f o r n i a A d v e n t i s t M a l e s , 1960-1980

ANIMAL 'RODUCT INDEX

RELATIVE RISK OF FATAL PROSTATE CA

NUMBER of DEATHS

Plant Proteins - ACS Publications - American Chemical Society

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