AMERICAN JOURNAL OF EPIDEMIOLOGY
Copyright © 1975 by The Johns Hopkins University School of Hygiene and Public Health
Vol. 102, No. 6 Printed in U.S.A.
Original Contributions EPIDEMIOLOGIC STUDIES OF CORONARY HEART DISEASE AND STROKE IN JAPANESE MEN LIVING IN JAPAN, HAWAII AND CALIFORNIA: INTRODUCTION1 S. L. SYME,2 M. G. MARMOT,2 A. KAGAN,3 H. KATO4 AND G. RHOADS3 Syme. S. L. (School of Public Health. U. of California. Berkeley. CA 94720). M. G. Marmot. A. Kagan, H. Kato and G. Rhoads. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: Introduction. Am J Epidemiol 102:477-480, 1975. It has been observed that among men of Japanese ancestry, there is a gradient in CHD mortality increasing from Japan to Hawaii to California. A study of 11,900 Japanese men in Hiroshima and Nagasaki, Japan, Honolulu, Hawaii, and the San Francisco Bay Area of California has been conducted to investigate this disease difference. This paper describes the selection of the study populations and their age distributions, and outlines the study methods. This paper also introduces and briefly summarizes four papers that give the results for mortality comparisons, biochemical and blood pressure distributions and results for heart disease prevalence among the three cohorts. blood pressure; coronary heart disease; epidemiology; glucose; lipids; migrants; mortality.
International comparisons of mortality from coronary heart disease (CHD) show marked differences in rates among countries (1). The USA has a rate among the Received for publication April 7, 1975, and in final form June 12, 1975. Abbreviation: CHD, coronary heart disease. 1 From the Epidemiology Program, School of Public Health, University of California at Berkeley; Honolulu Heart Study, Honolulu, Hawaii; and the Atomic Bomb Casualty Commission, Hiroshima and Nagasaki, Japan. Supported by: Grant No. 5 P01 NB06818 from the National Institute of Neurological Diseases and Stroke, Grant No. HL14783 from the National Heart and Lung Institute, the National Heart and Lung Institute Intramural Program, and by funds of the National Heart and Lung Institute made available to the Atomic Bomb Casualty Commission through the Atomic Energy Commission. Computing assistance was obtained from the Health Sciences Computing Facility, University of California at Los Angeles, sponsored by National Institutes of Health Special Research Resources Grant RR-3. 'Program in Epidemiology, School of Public Health, University of California at Berkeley. 'Honolulu Heart Study, Honolulu, Hawaii. 'Department of Epidemiology and Statistics, Atomic Bomb Casualty Commission, Hiroshima, and
highest recorded and Japan a rate among the lowest. While these international comparisons are productive of hypotheses concerning the etiology of CHD, the testing of these hypotheses is confounded by concomitant genetic, environmental and cultural variation between countries and by differences in the observational techniques used from one country to another. The study of migrants to some extent overcomes these difficulties (2). In the case of Japan, large numbers of Japanese migrated to Hawaii and California late in the 19th and early in the 20th century. Using vital statistics data, Gordon (3, 4) reported a gradient of CHD mortality such that men Hiroshima Branch, Japanese National Institute of Health, Hiroshima, Japan. The combined articles in this issue on "Epidemiologic Studies of Coronary Heart Disease and Stroke in Japanese Men Living in Japan, Hawaii and California," are available on request from: Epidemiology Research Unit, Dept. of Biomedical and Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA 94720.
477
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SYME, MARMOT, KAGAN, KATO AND RHOADS
of Japanese ancestry living in the USA experience rates that are intermediate between the low levels in Japan and the high levels experienced by Caucasian Americans. Gordon also showed a gradient of increasing CHD mortality among Japanese men from Japan to Hawaii to California (3). It is of considerable interest that the gradient for cerebrovascular disease mortality was in the opposite direction, i.e., a very high rate in Japan and a much lower rate among Japanese-Americans. It is possible that these mortality differences reflect differences in modes of reporting cause of death in Japan, Hawaii, and California. The present series of papers is from a collaborative study of Japanese men living in Japan, Hawaii and California which was undertaken to explore the validity of the reported mortality statistics and to determine if the gradient in CHD death rates could be validated by carefully collected prevalence and incidence data. Since much current information on CHD risk factors has been obtained from homogeneous population subgroups within single countries, this study also presented a unique opportunity to study the significance of a variety of CHD risk factors in one racial group living under very diverse environmental and cultural conditions. In this collaborative study, the investigators have sought to overcome another potential pitfall of international comparisons by using only standardized methods to assess prevalence of cardiovascular disease and other characteristics in the three study groups. The epidemiologic study in Japan was incorporated into the continuing investigations of the Atomic Bomb Casualty Commission in Hiroshima and Nagasaki. It was felt that this was an appropriate choice of sample as a majority of the Japanese migrants in Hawaii and California had originated from this geographic region of Japan. In Hawaii and California, attempts were made to study complete cohorts of men of Japanese ancestry living on the
island of Oahu and in the San Francisco Bay Area, respectively. This study has been described in detail by Kagan et al. (5). The Japanese sample was selected from the 20,000 people in the Adult Health Study Sample (6) under clinical surveillance by the Atomic Bomb Casualty Commission in Hiroshima and Nagasaki as part of its investigation of the late effects of ionizing radiation. Prospective studies in these cities have shown no relationship between exposure to radiation and occurrence of CHD (7). All the males aged 45-69 from Hiroshima and Nagasaki, alive on January 1, 1965, were selected for clinical study, yielding 2989 subjects. Abut 10 per cent of these men had emigrated from the cities of study and were unavailable for clinical observation. Of the remainder, the participation rate was approximately 80 per cent, with 2141 men undergoing examination. In Hawaii, it was estimated by extrapolation from the 1960 Census that approximately 14,400 men of Japanese ancestry aged 45-69 were living on the Island of Oahu in 1965. Attempts were made to identify these men using selective service registration records and a total of 11,148 were thus located (8). Of these, 8006 men underwent examination in 1965-1968. In California, a special census was initiated in 1967 to locate Japanese-Americans living in eight San Francisco Bay Area counties. The completeness of this census was assessed by a door-to-door survey in selected census tracts and under-enumeration was found to be less than 4 per cent. The men thus enumerated were invited to participate in a multiphasic examination in 1969-1970. The enumeration yielded 2733 men of appropriate residence, and aged 45-69. Of these, 1842 men were examined. The sample sizes by age and response rates for all three areas are summarized in table 1. Summary measures of demographic, physical, dietary, and biochemical charac-
Downloaded from https://academic.oup.com/aje/article-abstract/102/6/477/71999 by Leiden University / LUMC user on 09 June 2018
EPIDEMIOLOGY OF CHD IN JAPANESE IN JAPAN AND AMERICA TABLE 1
Age distribution and response rates of Japanese men examined in the three geographic locations No. examined Age (years) 45-49 50-54 55-59 60-64 65-69 Total No. examined Response rate: % of those eligible
Japan
Hawaii
California
294 445 452 514 436
1832 2792 1593 1338 451
728 522 272 165 155
2141 80%
8006 72%
1842 68%
teristics in the three cohorts have already been described by Kagan et al. (5). The present series of papers details the ascertainment of mortality in the three groups (9), methods of determination and distribution of biochemical variables (10), description of the blood pressure distributions and relationship to relative weight (11), and comparison of prevalence of coronary and hypertensive heart disease and their relation to serum cholesterol and blood pressure (12). The methods pertinent to the particular focus of study are presented separately in each of the papers that follow. Enlargement of the Japanese sample for the mortality comparison is detailed in the relevant paper. A crucial feature of this collaborative investigation has been the use of standardized methods. A uniform study protocol was formulated in advance by the principal investigators and followed in each of the three study sites. This included the use of a central laboratory to code all electrocardiograms blind as to their geographic origin, the use of standardized questionnaires and physical examination methods, and standardization of biochemical determinations within and between laboratories (13). In the paper on mortality, Worth et al. (9) explore the possible sources of bias inherent in an international comparison of mortality. The mortality rates presented
479
confirm Gordon's reported gradient: for coronary heart disease the mortality rate among these Japanese men increased from Japan to Hawaii to California, although the Hawaii-California differences did not achieve statistical significance at each age group. When comparisons were made with CHD mortality rates from Framingham, the gradient was extended, with white Americans having the highest rates. For stroke, the Japan cohort had the highest mortality rate, and the rates among the two Japanese-American groups were similar to those from Framingham. In the earlier paper by Kagan et al. (5), the Japanese-American groups had been shown to have higher mean serum cholesterols, higher mean glucose levels (onehour post-load) and higher mean uric acid levels than the Japan population. Although mean differences represent only an incomplete way of comparing population characteristics, the comparisons of the distributions of these variables and of fasting serum triglycerides in the paper by Nichaman et al. (10), confirm that real differences do exist between these populations: higher serum lipid levels and post-load serum glucose levels were seen in the Japanese-Americans. As the determinants of blood pressure levels are still shrouded in mystery despite a vast amount of research on the subject and as blood pressure may be a risk factor for both coronary heart disease and stroke, the comparison of blood pressure levels in these three populations was of great interest. Winkelstein et al. (11) explore the blood pressure distributions and show that, in general, the blood pressures of the California Japanese are higher than for the other two groups. Between Hawaii and Japan the differences are small. Statistical adjustment for the greater body weight of the Japanese-Americans reduced these differences. The prevalence of coronary heart disease is shown by Marmot et al. (12) to follow the same general Japan-Hawaii-California gra-
Downloaded from https://academic.oup.com/aje/article-abstract/102/6/477/71999 by Leiden University / LUMC user on 09 June 2018
480
SYME, MARMOT, KAGAN, KATO AND RHOADS
dient as the mortality rates, although in the case of prevalence rates the CaliforniaHawaii difference is greater than the Hawaii-Japan difference. It appears that the difference between the California Japanese and the other two cohorts cannot be explained by differences in the prevalence of hypertension or elevated serum cholesterol. It should be stressed that the last three of these papers are based on cross-sectional data and all the reservations that pertain to inferences from prevalence data must be borne in mind. However, if the incidence rates from this study confirm that differences in serum cholesterol, blood pressure, and smoking do not account for the higher rates of CHD seen among Japanese migrants to the continental United States, then this should provide valuable new insights into the epidemiology of coronary heart disease. Further analyses from this study will pursue the possible effects of obesity and of cultural and dietary change on changing rates of this disease.
6.
7.
8.
9.
10.
11.
REFERENCES
1. Report of Inter-Society Commission for Heart Disease Resources (J. Stamler, A. Lilienfeld chairmen). Primary prevention of the atherosclerotic diseases. Circulation 42:A55-A95, 1970 2. Reid DD: The future of migrant studies. Isr J Med Sci 7:1592-1596, 1971 3. Gordon T: Mortality experience among the Japanese in the United States, Hawaii and Japan. Public Health Rep 72:543-553, 1957 4. Gordon T: Further mortality experience among Japanese Americans. Public Health Rep 82:973-984, 1967 5. Kagan A, Harris BR, Winkelstein W, et al:
12.
13.
Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: demographic, physical, dietary, and biochemical characteristics. J Chronic Dis 27:345-364, 1974 Beebe GW, Fujisawa H, Yamasaki M: Adult Health Study Reference Papers. A. Selection of the Sample. B. Characteristics of the Sample. Atomic Bomb Casualty Commission Technical Report 10-60, 1960 Johnson KG, Yano K, Kato H: Coronary heart disease in Hiroshima. Report of a six-year-period of surveillance, 1958-1964. Am J Public Health 58:1355-67, 1968 Worth RM, Kagan A: Ascertainment of men of Japanese ancestry in Hawaii through World War II selective service registration. J Chronic Dis 23:389-397, 1970 Worth RM, Kato H, Rhoads G, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: mortality. Am J Epidemiol 102:481-490, 1975 Nichaman MZ, Hamilton HB, Kagan A, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: distribution of biochemical risk factors. Am J Epidemiol 102:491-501, 1975 Winkelstein W, Kagan A, Kato H, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: blood pressure distributions. Am J Epidemiol 102:502-513, 1975 Marmot MG, Syme SL, Kagan A, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: prevalence of coronary and hypertensive heart disease and associated risk factors. Am J Epidemiol 102:514-525, 1975 Belsky JL, Kagan A, Syme SL:. Epidemiologic Studies of Coronary Heart Disease and Stroke in Japanese Men Living in Japan, Hawaii and California. Research Plan. Atomic Bomb Casualty Commission Technical Report 12-71, 1971. Mi,crofiched and stored at: Bay Microfilm, Inc, 737 Loma Verde Avenue, Palo Alto, CA
Downloaded from https://academic.oup.com/aje/article-abstract/102/6/477/71999 by Leiden University / LUMC user on 09 June 2018
Copyright © 1975 by The Johns Hopkins University School of Hygiene and Public Health
Vol. 102, No. 6 Printed in U.S.A.
Original Contributions EPIDEMIOLOGIC STUDIES OF CORONARY HEART DISEASE AND STROKE IN JAPANESE MEN LIVING IN JAPAN, HAWAII AND CALIFORNIA: INTRODUCTION1 S. L. SYME,2 M. G. MARMOT,2 A. KAGAN,3 H. KATO4 AND G. RHOADS3 Syme. S. L. (School of Public Health. U. of California. Berkeley. CA 94720). M. G. Marmot. A. Kagan, H. Kato and G. Rhoads. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: Introduction. Am J Epidemiol 102:477-480, 1975. It has been observed that among men of Japanese ancestry, there is a gradient in CHD mortality increasing from Japan to Hawaii to California. A study of 11,900 Japanese men in Hiroshima and Nagasaki, Japan, Honolulu, Hawaii, and the San Francisco Bay Area of California has been conducted to investigate this disease difference. This paper describes the selection of the study populations and their age distributions, and outlines the study methods. This paper also introduces and briefly summarizes four papers that give the results for mortality comparisons, biochemical and blood pressure distributions and results for heart disease prevalence among the three cohorts. blood pressure; coronary heart disease; epidemiology; glucose; lipids; migrants; mortality.
International comparisons of mortality from coronary heart disease (CHD) show marked differences in rates among countries (1). The USA has a rate among the Received for publication April 7, 1975, and in final form June 12, 1975. Abbreviation: CHD, coronary heart disease. 1 From the Epidemiology Program, School of Public Health, University of California at Berkeley; Honolulu Heart Study, Honolulu, Hawaii; and the Atomic Bomb Casualty Commission, Hiroshima and Nagasaki, Japan. Supported by: Grant No. 5 P01 NB06818 from the National Institute of Neurological Diseases and Stroke, Grant No. HL14783 from the National Heart and Lung Institute, the National Heart and Lung Institute Intramural Program, and by funds of the National Heart and Lung Institute made available to the Atomic Bomb Casualty Commission through the Atomic Energy Commission. Computing assistance was obtained from the Health Sciences Computing Facility, University of California at Los Angeles, sponsored by National Institutes of Health Special Research Resources Grant RR-3. 'Program in Epidemiology, School of Public Health, University of California at Berkeley. 'Honolulu Heart Study, Honolulu, Hawaii. 'Department of Epidemiology and Statistics, Atomic Bomb Casualty Commission, Hiroshima, and
highest recorded and Japan a rate among the lowest. While these international comparisons are productive of hypotheses concerning the etiology of CHD, the testing of these hypotheses is confounded by concomitant genetic, environmental and cultural variation between countries and by differences in the observational techniques used from one country to another. The study of migrants to some extent overcomes these difficulties (2). In the case of Japan, large numbers of Japanese migrated to Hawaii and California late in the 19th and early in the 20th century. Using vital statistics data, Gordon (3, 4) reported a gradient of CHD mortality such that men Hiroshima Branch, Japanese National Institute of Health, Hiroshima, Japan. The combined articles in this issue on "Epidemiologic Studies of Coronary Heart Disease and Stroke in Japanese Men Living in Japan, Hawaii and California," are available on request from: Epidemiology Research Unit, Dept. of Biomedical and Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA 94720.
477
Downloaded from https://academic.oup.com/aje/article-abstract/102/6/477/71999 by Leiden University / LUMC user on 09 June 2018
478
SYME, MARMOT, KAGAN, KATO AND RHOADS
of Japanese ancestry living in the USA experience rates that are intermediate between the low levels in Japan and the high levels experienced by Caucasian Americans. Gordon also showed a gradient of increasing CHD mortality among Japanese men from Japan to Hawaii to California (3). It is of considerable interest that the gradient for cerebrovascular disease mortality was in the opposite direction, i.e., a very high rate in Japan and a much lower rate among Japanese-Americans. It is possible that these mortality differences reflect differences in modes of reporting cause of death in Japan, Hawaii, and California. The present series of papers is from a collaborative study of Japanese men living in Japan, Hawaii and California which was undertaken to explore the validity of the reported mortality statistics and to determine if the gradient in CHD death rates could be validated by carefully collected prevalence and incidence data. Since much current information on CHD risk factors has been obtained from homogeneous population subgroups within single countries, this study also presented a unique opportunity to study the significance of a variety of CHD risk factors in one racial group living under very diverse environmental and cultural conditions. In this collaborative study, the investigators have sought to overcome another potential pitfall of international comparisons by using only standardized methods to assess prevalence of cardiovascular disease and other characteristics in the three study groups. The epidemiologic study in Japan was incorporated into the continuing investigations of the Atomic Bomb Casualty Commission in Hiroshima and Nagasaki. It was felt that this was an appropriate choice of sample as a majority of the Japanese migrants in Hawaii and California had originated from this geographic region of Japan. In Hawaii and California, attempts were made to study complete cohorts of men of Japanese ancestry living on the
island of Oahu and in the San Francisco Bay Area, respectively. This study has been described in detail by Kagan et al. (5). The Japanese sample was selected from the 20,000 people in the Adult Health Study Sample (6) under clinical surveillance by the Atomic Bomb Casualty Commission in Hiroshima and Nagasaki as part of its investigation of the late effects of ionizing radiation. Prospective studies in these cities have shown no relationship between exposure to radiation and occurrence of CHD (7). All the males aged 45-69 from Hiroshima and Nagasaki, alive on January 1, 1965, were selected for clinical study, yielding 2989 subjects. Abut 10 per cent of these men had emigrated from the cities of study and were unavailable for clinical observation. Of the remainder, the participation rate was approximately 80 per cent, with 2141 men undergoing examination. In Hawaii, it was estimated by extrapolation from the 1960 Census that approximately 14,400 men of Japanese ancestry aged 45-69 were living on the Island of Oahu in 1965. Attempts were made to identify these men using selective service registration records and a total of 11,148 were thus located (8). Of these, 8006 men underwent examination in 1965-1968. In California, a special census was initiated in 1967 to locate Japanese-Americans living in eight San Francisco Bay Area counties. The completeness of this census was assessed by a door-to-door survey in selected census tracts and under-enumeration was found to be less than 4 per cent. The men thus enumerated were invited to participate in a multiphasic examination in 1969-1970. The enumeration yielded 2733 men of appropriate residence, and aged 45-69. Of these, 1842 men were examined. The sample sizes by age and response rates for all three areas are summarized in table 1. Summary measures of demographic, physical, dietary, and biochemical charac-
Downloaded from https://academic.oup.com/aje/article-abstract/102/6/477/71999 by Leiden University / LUMC user on 09 June 2018
EPIDEMIOLOGY OF CHD IN JAPANESE IN JAPAN AND AMERICA TABLE 1
Age distribution and response rates of Japanese men examined in the three geographic locations No. examined Age (years) 45-49 50-54 55-59 60-64 65-69 Total No. examined Response rate: % of those eligible
Japan
Hawaii
California
294 445 452 514 436
1832 2792 1593 1338 451
728 522 272 165 155
2141 80%
8006 72%
1842 68%
teristics in the three cohorts have already been described by Kagan et al. (5). The present series of papers details the ascertainment of mortality in the three groups (9), methods of determination and distribution of biochemical variables (10), description of the blood pressure distributions and relationship to relative weight (11), and comparison of prevalence of coronary and hypertensive heart disease and their relation to serum cholesterol and blood pressure (12). The methods pertinent to the particular focus of study are presented separately in each of the papers that follow. Enlargement of the Japanese sample for the mortality comparison is detailed in the relevant paper. A crucial feature of this collaborative investigation has been the use of standardized methods. A uniform study protocol was formulated in advance by the principal investigators and followed in each of the three study sites. This included the use of a central laboratory to code all electrocardiograms blind as to their geographic origin, the use of standardized questionnaires and physical examination methods, and standardization of biochemical determinations within and between laboratories (13). In the paper on mortality, Worth et al. (9) explore the possible sources of bias inherent in an international comparison of mortality. The mortality rates presented
479
confirm Gordon's reported gradient: for coronary heart disease the mortality rate among these Japanese men increased from Japan to Hawaii to California, although the Hawaii-California differences did not achieve statistical significance at each age group. When comparisons were made with CHD mortality rates from Framingham, the gradient was extended, with white Americans having the highest rates. For stroke, the Japan cohort had the highest mortality rate, and the rates among the two Japanese-American groups were similar to those from Framingham. In the earlier paper by Kagan et al. (5), the Japanese-American groups had been shown to have higher mean serum cholesterols, higher mean glucose levels (onehour post-load) and higher mean uric acid levels than the Japan population. Although mean differences represent only an incomplete way of comparing population characteristics, the comparisons of the distributions of these variables and of fasting serum triglycerides in the paper by Nichaman et al. (10), confirm that real differences do exist between these populations: higher serum lipid levels and post-load serum glucose levels were seen in the Japanese-Americans. As the determinants of blood pressure levels are still shrouded in mystery despite a vast amount of research on the subject and as blood pressure may be a risk factor for both coronary heart disease and stroke, the comparison of blood pressure levels in these three populations was of great interest. Winkelstein et al. (11) explore the blood pressure distributions and show that, in general, the blood pressures of the California Japanese are higher than for the other two groups. Between Hawaii and Japan the differences are small. Statistical adjustment for the greater body weight of the Japanese-Americans reduced these differences. The prevalence of coronary heart disease is shown by Marmot et al. (12) to follow the same general Japan-Hawaii-California gra-
Downloaded from https://academic.oup.com/aje/article-abstract/102/6/477/71999 by Leiden University / LUMC user on 09 June 2018
480
SYME, MARMOT, KAGAN, KATO AND RHOADS
dient as the mortality rates, although in the case of prevalence rates the CaliforniaHawaii difference is greater than the Hawaii-Japan difference. It appears that the difference between the California Japanese and the other two cohorts cannot be explained by differences in the prevalence of hypertension or elevated serum cholesterol. It should be stressed that the last three of these papers are based on cross-sectional data and all the reservations that pertain to inferences from prevalence data must be borne in mind. However, if the incidence rates from this study confirm that differences in serum cholesterol, blood pressure, and smoking do not account for the higher rates of CHD seen among Japanese migrants to the continental United States, then this should provide valuable new insights into the epidemiology of coronary heart disease. Further analyses from this study will pursue the possible effects of obesity and of cultural and dietary change on changing rates of this disease.
6.
7.
8.
9.
10.
11.
REFERENCES
1. Report of Inter-Society Commission for Heart Disease Resources (J. Stamler, A. Lilienfeld chairmen). Primary prevention of the atherosclerotic diseases. Circulation 42:A55-A95, 1970 2. Reid DD: The future of migrant studies. Isr J Med Sci 7:1592-1596, 1971 3. Gordon T: Mortality experience among the Japanese in the United States, Hawaii and Japan. Public Health Rep 72:543-553, 1957 4. Gordon T: Further mortality experience among Japanese Americans. Public Health Rep 82:973-984, 1967 5. Kagan A, Harris BR, Winkelstein W, et al:
12.
13.
Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: demographic, physical, dietary, and biochemical characteristics. J Chronic Dis 27:345-364, 1974 Beebe GW, Fujisawa H, Yamasaki M: Adult Health Study Reference Papers. A. Selection of the Sample. B. Characteristics of the Sample. Atomic Bomb Casualty Commission Technical Report 10-60, 1960 Johnson KG, Yano K, Kato H: Coronary heart disease in Hiroshima. Report of a six-year-period of surveillance, 1958-1964. Am J Public Health 58:1355-67, 1968 Worth RM, Kagan A: Ascertainment of men of Japanese ancestry in Hawaii through World War II selective service registration. J Chronic Dis 23:389-397, 1970 Worth RM, Kato H, Rhoads G, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: mortality. Am J Epidemiol 102:481-490, 1975 Nichaman MZ, Hamilton HB, Kagan A, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: distribution of biochemical risk factors. Am J Epidemiol 102:491-501, 1975 Winkelstein W, Kagan A, Kato H, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: blood pressure distributions. Am J Epidemiol 102:502-513, 1975 Marmot MG, Syme SL, Kagan A, et al: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: prevalence of coronary and hypertensive heart disease and associated risk factors. Am J Epidemiol 102:514-525, 1975 Belsky JL, Kagan A, Syme SL:. Epidemiologic Studies of Coronary Heart Disease and Stroke in Japanese Men Living in Japan, Hawaii and California. Research Plan. Atomic Bomb Casualty Commission Technical Report 12-71, 1971. Mi,crofiched and stored at: Bay Microfilm, Inc, 737 Loma Verde Avenue, Palo Alto, CA
Downloaded from https://academic.oup.com/aje/article-abstract/102/6/477/71999 by Leiden University / LUMC user on 09 June 2018
