Coronary Heart Disease Risk Factors in Men - NCBI

Coronary Heart Disease Risk Factors in Men With Light and Dark Skin in Puerto Rico RAUL COSTAS, JR., MD, MARIO R. GARCIA-PALMIERI, MD, PAUL SORLIE, MS, AND ELLEN HERTZMARK, MA

Abstract: The association of skin color with coronary heart disease risk factors was studied in 4,000 urban Puerto Rican men. Skin color on the inner upper arm was classified according to the von Luschan color tiles. Using this grading, men were separated into two groups of light or dark skin color. The dark group had a lower socioeconomic status (SES) based on income, education, and occupation. Dark men had slightly higher mean systolic blood pressures (SBP) and lower

mean serum cholesterol levels than the light, but the relative weights and cigarette smoking habits of both groups were similar. After controlling for the differences in SES, skin color showed a small but statistically significant association with SBP. Whether this association with skin color represents genetic or environmental influences on SBP could not be determined from this study. (Am J Public Health 1981; 71:614619.)

Introduction

Ethnic Background of Puerto Rico The people of Puerto Rico are descended, in order of their appearance on the island, from Taino Indians, Spaniards, West Africans, and non-Spanish Europeans.' The Indians, never a large number to begin with (estimated at 30,000 to 50,000),8 were decimated by the Spaniards in various uprisings, so that by the year 1787 only 2,302 survivors were reported in the census.9 Racial admixture between Spaniards and Indians had occurred early and frequently. In the year 1530, of 71 women legally married to Spaniards in San Juan, 14 were Indians.9 The social integration of West Africans in Puerto Rico differs from that in mainland United States. Spanish culture was impregnated with Catholic religious values. The church, an important influence in early Puerto Rican history, never sanctioned the chattel status of the Blacks nor did it segregate them.'0 Considerable intermarriage took place from earliest times." Mulatto children would frequently inherit land from their White fathers, thus becoming landowners and improving their economic situation. Pure Blacks, however, had to work for very low wages after slavery was officially abolished in 1873. Since 1873 there has been legal'2 and political'3 equality for Blacks in Puerto Rico. However, census data between 1899 and 1950 reveal a general historic pattern of drastic underrepresentation of Blacks in occupations related to social and economic improvement and social prestige.'4 This pattern was related to the influx into Puerto Rico of American capital.'2 A study conducted by a special committee of the Commonwealth House of Representatives as late as 196414 showed discrimination against Blacks in the employee selection system for Puerto Rican banks. In 1969, the Puerto Rican Senate'4 found discriminatory hiring practices for private school teachers. At the present time a casual visit to any

Differences in mean blood pressure values between Blacks and Whites in the continental United States have been observed in various studies." 2 Investigations have centered on ascribing the higher blood pressure values in Blacks to the effect of psychosocial processes or geneticenvironmental interactions.3-6 High blood pressure is recognized as one of the more potent factors for the development of coronary heart disease. It is related to and possibly interacts with other risk factors to accelerate the development of this disease. This multiple potential for illness, disability, and death makes the clarification of the etiology of the higher blood pressure in Blacks of prime importance, particularly in view of the longterm public health goal, the primary prevention of hypertension. In an attempt to gather data relevant to this question, skin color was determined for subjects of the Puerto Rico Heart Health Program, a prospective study of the epidemiology of coronary heart disease. In addition to blood pressure, various other factors studied in relation to skin color were relative weight, physical activity, serum cholesterol, fasting serum triglycerides, blood glucose, and measures of income, education, and occupation.

Address reprint requests to Paul Sorlie, MS, Health Statistician, Biometrics Research Branch, National Heart, Lung, and Blood Institute, Federal Building, Room 2A06, Bethesda, MD 20205. The three co-authors are with the Department of Medicine, School of Medicine, University of Puerto Rico, San Juan, PR. This paper, submitted to the Journal September 4, 1980, was revised and accepted for publication November 25, 1980.

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AJPH June 1981, Vol. 71, No. 6

CHD RISK FACTORS IN MEN WITH LIGHT AND DARK SKIN

bank or other commercial institution will show that such discriminatory practices are in the process of being dismantled. For many years it was thought that the Indians of Puerto Rico had died out and were no longer contributing to the gene pool. If so, skin color would be a simple, if crUde, proxy for the degree of Black-White admixture. However, Indian genes seem to be present in the population at greater than trivial levels. Thieme found shovel-shaped incisors (a "'mongolian" genetic marker) in approximately 19 per cent of a representative island-wide sample.'5 From historical sources and from the geographical distribution of shovelshaped incisors, Indian admixture is likely to be greatest in the hilly rural interior of the island. This means that the population in the rural area of this study would have the greatest amount of Indian genes. Urban subjects would have an indeterminate proportion of Indian admixture because of the large rural to urban migration that has taken place in Puerto Rico since the 1940s.

Materials and Methods The Puerto Rico Heart Health Program is a prospective study of coronary heart disease in a cohort of 9,824 Puerto Rican men, the majority between 45 and 64 years of age at entry, residing in the urban municipalities of Bayamon, Guaynabo, and Carolina near the coastal plain, and the rural municipalities of Naranjito, Comerio, Barranquitas, and Corozal in the hilly interior of the island.'6 Subjects had a social, dietary, and medical history taken, and a physical examination, electrocardiogram, and blood chemistries performed at periodic clinic visits to determine the presence of risk factors and to detect cardiovascular disease outcomes. A physician measured the blood pressure on the left arm of the seated subject, both at the beginning and after completion of the physical examination, using an aneroid sphygmomanometer standardized against a mercury apparatus. The second blood pressure reading was used for the Tables in this paper. Relative weight, expressed as a per cent, was computed as the ratio of the observed weight to the ideal weight for the observed height taken from Metropolitan Life Insurance tables. 17 The physical activity index was based on the weighted number of hours spent in each of five physical activity levels.'8 The codes used for education level attained were: (1) first to fourth grade; (2) fifth to eighth grade; (3) high school attendance; (4) high school graduation; and (5) university attendance or graduation. The codes used for occupation were: (0) unskilled labor; (1) skilled labor; (2) office or sales personnel; (3) supervisors or administrators; and (4) professionals. The serum cholesterol was determined by the method of Huang, et al, '9 the serum triglycerides by the method of van Handel and Zilversmit,20 and the blood glucose by the Somogyi-Nelson method.2' Skin color was determined at the third examination, almost six years after the initial visit. The Anthropology Department of the Smithsonian Institution in Washington, DC recommended the use of the von Luschan color tiles22 to determine skin color. The von Luschan color tiles consisted of 30 colored tiles representing shades of skin color from AJPH June 1981, Vol. 71, No. 6

TABLE 1 Puerto Rico Heart Study Population by Age and Skin Color of Urban Men 35-79 Years at Examination 1

Age (years)

35-44 45-54 55-64

65-79 TOTAL

%

97 1918 1204 161 3380

Total

Dark

Light

2.9 56.7 35.6 4.8 100

%

15 314 244 47 620

2.4 50.6 39.4 7.6 100

112 2232 1448 208 4000

very light to very dark. A photographic reproduction of the tiles was matched to the skin color on the inner arm, where the skin presumably would be minimally affected by the sun. In an attempt to reduce inter-observer variability in assessing skin color, all determinations were made by the same individual. The data were analyzed by dichotomizing the scale into those with light skin and those with dark skin (tiles numbered 23 to 30 were classified as dark). Analyses presented in this paper will use data from the urban area only. The earlier discussion of Indian admixture indicates that the urban area would tend to be the least affected. Furthermore, consistent with historical development, there are few individuals with dark skin in the rural area (101 persons from a population of 1,784), thus making estimates subject to much higher variability and making analyses by subclasses (e.g., age) very tenuous. To describe differences in characteristics by skin color group, mean values were calculated for the light and dark populations. The statistical significance of the difference in these means was tested with the t-test. A multivariate analysis of these differences was done using the multiple discriminant function analysis. If a coefficient of the discriminant function is statistically different from zero, then the difference in means for that variable is interpreted to be statistically different from zero when the other variables are taken into account. Analysis of factors related specifically to blood pressure was done by calculating simple product moment correlations between these factors and blood pressure, and by multiple linear regression of systolic blood pressure on these factors.

Results Of the 6,843 urban men who entered the Puerto Rico Heart Program in 1965, skin color was determined in 4,000 subjects at the third examination, almost six years later. Mean values of the risk factors under consideration were compared for those men with and without skin color measurement and no differences were found. Thus, there is no reason to believe that there is any bias in the population which had the determinations of skin color. The frequency of light and dark skin within the urban groups by age is shown in Table 1. The dark group shows an age distribution only slightly older than the light group. 615

COSTAS, ET AL. TABLE 2-Mean Values of Specified Characteristics by Skin Color Group In Urban Men, Age 35-79 at Examination 1, Puerto Rico Heart Health Program Variables at Initial Examination

Light Skin

Dark Skin

Systolic Blood Pressure (mm Hg) Diastolic Blood Pressure (mm Hg) Serum Cholesterol (mg/dl) Fasting Triglycerides (mg/dl) Blood Glucose (mg/dl) Relative Weight (%) Physical Activity (index) Cigarettes Smoked (#/day) Age (years) Income ($/month) Education Occupation Number with Known Values (N for Fasting Triglycerides)

131 83 206 164 97 117 31 7.6 54 499 2.5 1.5 3268 (1979)

135** 84* 197** 131** 97 115 33** 7.4 55** 300** 1.8** 1.0** 594 (360)

*t-test for difference in means, p < .05 **t-test for difference in means, p < .01

TABLE 3-Correlation between Systolic Blood Pressure and Specified Characteristics at Initial Examination within Skin Color Groups of Urban Men, Age 35-79, Puerto Rico Heart Heahh Program Variables at Initial Examination

SBP vs: Serum Cholesterol Fasting Triglycerides Blood Glucose Relative Weight Physical Activity Cigarettes Smoked Age Income Education Occupation N (N for Fasting Triglycerides)

Light Skin

Dark Skin

0.09** 0.08** 0.09** 0.23** -0.06** -0.09** 0.22** 0.02 0.01 0.05* 3268

0.13* 0.04 0.05 0.24** -0.03

-0.09 0.17** 0.03 0.06 0.03 594

(1979)

(360)

*p < .05 **p < .01

Table 2 shows the mean values of selected variables at Examination 1 according to skin color. The dark group had higher average systolic and diastolic blood pressure, lower serum cholesterol and fasting triglycerides, and similar average blood glucose. Each skin color group reported smoking the same quantity of cigarettes per day. Although not shown, heart rate and hematocrit were similar in the two skin color groups. The dark group was only one year older on the average than the light group, but this difference was statistically significant. Income, education, and occupation level were all lower in the dark group. The population was queried on antihypertensive drug use, including diuretics, and 15 per cent of the dark and 14 per cent of the light group were reported to be using antihypertensive medication. If those individuals taking antihypertensive drugs are removed from the analysis, the differences by color shown in Table 2 are virtually unchanged. Since diastolic blood pressure was only slightly higher in the dark group, all subsequent Tables will present the results using systolic pressure. Simple correlation coefficients between systolic blood pressure and specific variables are shown in Table 3. As would be expected, relative weight and age had the strongest association with systolic pressure. No important association with blood pressure was apparent for any of the socioeconomic variables studied (income, education, and occupation). Multiple discriminant function analysis was run, using systolic blood pressure and the other characteristics as possible variables to maximize the discrimination between the two populations of light and dark skin. Results of these analyses are shown in Table 4. In this particular multivariate modeling, there were significant differences for systolic pressure, serum cholesterol, physical activity, age, education, and occupation between the two skin color groups when all of the variables were taken into account. That is, systolic blood pressure was still higher in the dark group when con616

trolling for the fact that this group was from a lower socioeconomic level. This is not too surprising in light of the previous Tables which show virtually no association between blood pressure and income, education, or occupation. The results in Table 4 indicate that there were other important differences between the light and dark groups. First, serum cholesterol tended to be lower and physical activity levels were higher in the dark group. Secondly, the measures of education and occupation were statistically significant and lower in the dark group. Triglycerides were included in this multivariate model for the subgroup that came to the examination in a fasting state (Table 4). These results show that the lower triglycerides in the dark group were statistically significant when the other variables were taken into account. Looking more specifically at the determinants of blood pressure, a multiple linear regression model was also fitted, and the resulting coefficients are shown in Table 5. Systolic blood pressure was regressed on skin color, serum cholesterol, blood glucose, relative weight, physical activity, cigarettes smoked, age, and the socioeconomic variables. Skin color was significantly associated with systolic blood pressure when the other variables were taken into account. There are, however, other variables which were significantly associated with systolic pressure and which had a much greater impact than skin color; age and relative weight were the dominant variables. After adjustment for the specified variables, the estimated difference in systolic blood pressure between light and dark was still about 4 mm Hg (coefficient is 4.0436 and skin color is coded 0 or 1, light or dark respectively). The inability of these parameters to adequately explain the variability of blood pressure is seen by the Rsquared value of 0.12, or only 12 per cent of SBP variability was explained by these variables. The Heart Study has only two and one-half years of morbidity and mortality follow-up on these men with skin color determinations yielding estimates of incidence rates AJPH June 1981, Vol. 71, No. 6

CHD RISK FACTORS IN MEN WITH LIGHT AND DARK SKIN TABLE 4-Multiple Discriminant Function Coefficients (MDFC) of Characteristics which Discriminate between the Light and Dark Groups of Urban Men, Puerto Rico Heart Health Program All Men Variable at Initial Examination

Systolic Blood Pressure Serum Cholesterol Blood Glucose Relative Weight Physical Activity Cigarette Smoking Age Income Education

Occupation Triglycerides (fasting) (# dark/# light)

MDFC

Fasting Men Only T-Value

0.0099** 4.48 -0.0045** -4.05 -0.0004 -0.28 0.0011 0.41 0.0396** 5.70 0.0028 0.76 0.0162* 2.05 -0.0001 -1.77 - 0.1 149** -3.02 -4.11 -0.1849** Not in this model (594: 3268)

MDFC

0.0089** -0.0037* 0.0013 0.0062 0.0416** 0.0050 0.0117 -0.0001 - 0. 1205* - 0. 1752** -0.0019** (360: 1979)

T-Value

3.15 -2.44 0.70 1.78 4.52 1.43 1.14 -1.50 -2.48 -3.07 -3.34

*p < .05 **p < .01

with wide confidence intervals. At this level of follow-up, no statements can be made comparing morbidity and mortality in the light and dark groups.

Discussion Blood pressure studies in Puerto Rico can be traced back to 1948, when an attempt was made to obtain blood pressures on an island-wide sample of the population aged 17-54.23 Racial classification in that study was made using the von Luschan tiles for skin color, as well as other morphological characteristics. When controlling for age, weight groups, nutritional class, climatological class, and socioeconomic class, there were no differences in blood pressures between Blacks and Whites for those who had always lived in the rural areas. This 1948 study did not analyze the urban population. The current study of urban men in the Puerto Rico Heart Health Program has shown higher average systolic blood pressure values than men with light skin, a situation similar to that found in the continental United States. However, while this difference in the Puerto Rico group is statistically significant, its magnitude is relatively small, only 4 mm Hg. There was only a small difference observed for diastolic blood pressure (1 mm Hg). Multivariate analysis in the present study shows that the higher observed average blood pressure in the dark group is not due to age, a variety of characteristics including relative weight, or the socioeconomic factors studied. Within Puerto Rico, the socioeconomic variables measured are not related to blood pressure, but they are related to other coronary risk factors (Figure 1). There is increasing serum cholesterol and relative weight with individuals of higher educational attainment. Mean values of systolic and diastolic blood pressure are fairly constant at all levels of education. Figure 1 also shows that at each level of educaAJPH June 1981, Vol. 71, No. 6

tion, systolic pressure is higher in the dark color group than the light. The inability of the socioeconomic factors to explain the blood pressure difference does not rule out the involvement of psychosocial processes. There are, of course, other psychosocial or environmental factors and cultural behavior which are not adequately measured by education, income, or occupation. These alternative hypotheses include lifelong differences in dietary practices such as salt intake, differences in family interactions such as marital dissatisfaction, differences in daily stress, or differences in goal achievements not directly measured by education, occupation, or income. From a 24-hour dietary recall collected at the initial examination, data have been analyzed to determine if there are major dietary differences between the light and dark groups. There are some differences as noted in Table 6, but these differences are not large. There is slightly less fat and more carbohydrates consumed in the dark group, while caffeine and cholesterol consumption in this group are less. In addition to blood pressure differences, the Puerto Rico study describes other major and possibly more important differences in coronary risk factors between skin color groups. In particular, serum cholesterol and fasting triglycerides are lower, and physical activity levels are higher in the dark group. Differences in lipoprotein measurements between Blacks and Whites have been observed elsewhere. In the Evans County study,24 Blacks were found to have lower serum triglycerides and lower low density lipoprotein cholesterol (LDL-C) than Whites after controlling for total serum cholesterol, age, and sex. Blacks also had higher values of high density lipoprotein cholesterol (HDL-C). In a similar analysis of the Cincinnati Lipid Research Clinic population, plasma HDL-C was higher in Blacks and plasma triglycerides were lower after controlling for total cholesterol, age, and sex.25 To try to resolve any controversy about the genetic or 617

COSTAS, ET AL. 60

Age

-

Dark

60

Skin Color

Light Skin Color

AGE (Years) 50

50

Relative

120

MOf IC)

110

120

We2ht0

RELATIVE WEIGHT

Ida110 Cholesterdo___-l

210 SERUM CHOLESTEROL SERUM

/

Nutrients

Light Skin

Dark Skin

Calories (Cal) Dietary Cholesterol (mg) Caffeine (mg) Per Cent Calories from Fat Protein

2432 454 209

2385 400* 190*

37 15 46 3

36* 14 47*

Carbohydrates Alcohol

-,p

serum

TABLE 6-Mean Values of Nutrients in Light and Dark Skin Subjects among Urban Men, 35-79 Years at Examination 1, 24-Hour Dietary Recall

_

3

210 *p < .05, t-test for difference in mean between light and dark

(mg/dl) 190 _

SYSTOLIC

BLOOD PRESSURE (mm Hg)

140

-

190

140

Systolic

B.P. ---

1

skin group has lower cholesterol levels while the light skin group has lower blood pressure measurements. Further work is needed to understand the reasons for these differences, and to improve the risk profiles in both groups.

130

REFERENCES DIASTOLIC BLOOD BLOOD PRESSURE (mm Hg)

90

90

B

~~~~~~~Diastolic ~~~~~~~B.P.

80 None

Grades 1-4

80 Grades High School High School University 5-8 Attended Graduate (Any)

EDUCATION LEVEL (EXAM 1) FIGURE 1-Mean Values of Specified Characteristics by Education and Skin Color; Urban Men, Puerto Rico Heart Health Program

environmental determinants of these differences would require extrapolation beyond the available data. We have not been able to eliminate the differences by statistical control of several socioeconomic variables, but we did not measure and thus could not consider a large number of confounding psychosocial and cultural variables. In Puerto Rico, the dark TABLE 5-Multiple Linear Regression Coefficients of Systolic Blood Pressure Regressed on Specified Characteristics of Urban Men, 35-79 Years at Examination 1, Puerto Rico Heart Health Program Coefficient

t-value

Skin Color Serum Cholesterol Blood Glucose Relative Weight Physical Activity

4.0436** 0.0437** 0.0311** 0.2778** -0.0427

4.37 5.39 3.08 14.49

Cigarette Smoking

-0.0608*

Age Income Education Occupation (N = 3862) (R2

0.8402** -0.0004 0.2269 0.3181

Independent Variables

*p < .05 **p < .01

618

=

0.12)

-0.84 -2.25 14.93 -0.85 0.82 0.97

1. McDonough JR, Garrison GE, Hames GG: Blood pressure and hypertensive disease among Negroes and Whites; a study in Evans County, Georgia. Ann Intern Med 1964; 61:208-288. 2. Hypertension Detection and Follow-up Program Cooperative Group: Race, education and prevalence of hypertension. Am J Epidemiol 1977; 106:351-361. 3. Keil JE, Tyroler HA, Sandifer SH, et al: Hypertension, effect of social class and racial admixture. Am J Public Health 1977; 67:634-639. 4. Tyroler HA, James SA: Blood pressure and skin color. Am J Public Health 1978; 68:1170-1172. 5. Harburg E, Gleibermann L, Roeper P, et al: Skin color, ethnicity, and blood pressure I: Detroit Blacks. Am J Public Health 1978; 68:1177-1183. 6. Harburg E, Gleibermann L, Ozgoran F, et al: Skin color, ethnicity, and blood pressure II. Detroit Whites. Am J Public Health 1978; 68:1184-1188. 7. Steward JH, Manners RA, Wolf ER, et al: The People of Puerto Rico, Urbana IL: University of Illinois Press, 1956. 8. Morales-Carrion A: Historia del Pueblo de Puerto Rico. Quoted by: Babin MT: La Cultura de Puerto Rico. San Juan, PR: Instituto de Cultura Puertorriquena, 1970, p. 49. 9. Brau S: La Colonizacion de Puerto Rico. Quoted by: Babin MT: La Cultura de Puerto Rico. San Juan, PR: Instituto de Cultura Puertorriquena, 1970, p. 49. 10. Hoetink H: The Two Variants in Caribbean Race Relations. London: Oxford University Press, 1967. 11. Gordon M: Cultural aspects of Puerto Rico's race problem. Am Social Rev 1950; 15:382-392. 12. Williams E: Race relations in Puerto Rico and the Virgin Islands. Foreign Affairs, January 1945. 13. Sagrera M: Racismo y Politica en Puerto Rico. Rio Piedras, PR: Editorial Edil, Inc., 1973, pp. 9-39. 14. Estudio para determinar el alcance y ramificaciones de la discriminacion por razon de color, sexo y origen nacional en la empresa privada en Puerto Rico. Center for Environmental and Consumer Justice, Diaz-Pabon N (trans), thesis, University of Puerto Rico, Rio Piedras, 1975. 15. Thieme FP: The Puerto Rican Population. A Study in Human Biology. Ann Arbor, MI: University of Michigan Press, 1959. 16. Garcia-Palmieri MR, Feliberti M, Costas R Jr, et al: An epidemiological study on coronary heart disease in Puerto Rico: The Puerto Rico Heart Health Program. Bol Asoc Med PR 1969; 61:174-179.


CHD RISK FACTORS IN MEN WITH LIGHT AND DARK SKIN 17. Metropolitan Life Insurance Company: New weight standards for men and women. Stat Bul Metropol Life Ins Co 1959; 40:14. 18. Torres R, Costas R Jr, Garcia-Palmieri MR; Statistical procedures for quality control in the Puerto Rico Heart Program. Bol Asoc Med PR 1969; 212-214. 19. Huang TC, Chen CP, Wefler V, et al: A stable reagent for the Liebermann-Burchard reaction: application to rapid cholesterol determination. Anal Chem 1961; 33:1405-1407. 20. Van Handel E, Zilversmit DB: Micromethod for the direct determination of serum triglyceride. J Lab Clin Med 1957; 50:152157. 21. Nelson N; A photometric adaptation of the Somogyi method for the determination of glucose. J Biol Chem 1944; 15:375-380. 22. Howells WW: The distribution of man. Sci Am 1960; 203:112127. 23. Murril RI: Racial blood pressure studies: A critique of methodology, with especial reference to the effect of age, nutrition, cli-

mate, and race on blood pressure in Puerto Rico. Proc Am Phil Soc 1955; 99:277-324. 24. Tyroler HA, Hames CG, Krishan 1, et al: Black-White differences in serum lipids and lipoproteins in Evans County. Prev Med 1975; 4:541-549. 25. Morrison JA, deGroot I, Kelly KA, et al: Black-White differences in plasma lipids and lipoprotein in adults: The Cincinnati Lipid Research Clinic Population Study. Prev Med 1979; 8:34-39.

ACKNOWLEDGMENTS The assistance of Mrs. Blanca Prez-Berrios, who did all the skin color determinations, is gratefully acknowledged. This investigation was supported by Contracts PH 43-63-620 and NOI HV 42902 from the National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Public Health Service, Bethesda, Maryland, to the University of Puerto Rico.

'Occupational Stress' Conference to be Held in June The Society for Occupational and Environmental Health will sponsor a national conference on "Occupational Stress: Consequences, Causes and Remedies" June 1-3, 1981 at the Lord Baltimore Hotel in Baltimore, MD. Stress-related illness is not only harmful to the worker, but is costly to society in general, contributing to loss of productivity and increasing health care costs. Previous efforts in this area have narrowly focused primarily on either industrial psychology, coping mechanisms for the worker and management, or other narrowly defined aspects of occupational stress. New research now contributes to an expanded perspective of this issue. The conference will provide a forum for a comprehensive review of occupational stress, place the issue of stress in perspective, and develop specific recommendations for remedial action on a variety of fronts. The conference format will include formal presentations, panels, and discussion and participatory workshops. Serving as Conference Co-Chairpersons are Irene A. Jillson, President, Policy Research Inc., Baltimore, MD, and Dr. Dennis Chamot, Assistant Director, AFL-CIO Department for Professional Employees. Copies of the preliminary conference agenda, and registration and housing forms are available from the Society for Occupational and Environmental Health, 2914 M Street NW, Washington, DC 20007, telephone 202/965-6633.


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