American Journal of Epidemiology
Copyright © 1998 by The Johns Hopkins University School of Hygiene and Public Health
All rights reserved
Vol. 148, No. 12
Printed in U.S.A.
Body Mass Index, Waist/Hip Ratio, and Coronary Heart Disease Incidence in
African Americans and Whites
Aaron R. Folsom,1 June Stevens,2 Pamela J. Schreiner,1 and Paul G. McGovern1 for the Atherosclerosis
Risk in Communities Study Investigators
To study the relation of the amount and distribution of body fat with incident coronary heart disease in two
ethnic groups, the authors analyzed prospective data from the Atherosclerosis Risk in Communities Study.
Among 14,040 participants aged 45-64 years and free of coronary disease at baseline in 1987-1989, we
identified 398 events through 1994, an average of 6.2 years of follow-up. Among African-American women, the
multivariable-adjusted relative risks of coronary heart disease across quartiles of body mass index were 1.0,
1.91. 1.54, and 2.15 (p for trend = 0.27), and those for waist/hip ratio were 1.0, 2.07, 2.33, and 4.22 (p for
trend = 0.02). Among African-American men, these respective relative risks were 1.0,1.03, 0.83, and 1.20 (p
for trend = 0.76) for body mass index and 1.0, 1.08, 1.87, and 1.68 (p for trend = 0.06) for waist/hip ratio.
Relative risks for whites were generally similar to those for African Americans. Relative risks were stronger for
never smokers than for the overall cohort. Unlike some previous studies, our results suggest that Africa
Americans, like whites, are not spared from the coronary heart disease risks accompanying obesity. Am J
Epidemiol 1998; 148:1187-94.
blacks; coronary disease; ethnic groups; obesity; weight
Extensive prospective epidemiologic research has
documented that moderate-to-severe obesity is an important risk factor for coronary heart disease (CHD),
either directly or indirectly through intervening risk
factors such as hypertension, dyslipidemia, and diabetes (1). Obesity and weight gain arising early in adulthood or occurring over long periods of follow-up seem
to convey particularly strong risks of CHD (2-5).
African Americans may have a lower weight-related
relative risk of cardiovascular disease than do whites
(6-11).
Independent of overall obesity, a relative preponderance of abdominal fat is associated with increased risk
of CHD (12-19). Abdominal (visceral) obesity is
strongly associated with metabolic risk factors for
CHD. Yet, researchers have not yet fully established
the importance of fat distribution for CHD occurrence
among African Americans.
Received for publication December 1, 1997, and accepted for
publication April 20, 1998.
Abbreviations: ARIC, Atherosclerosis Risk in Communities Study;
BMI, body mass index; C-index, conicity index; CHD, coronary
heart disease; Cl, confidence interval; RR, relative risk.
1
Division of Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, MN.
2
Departments of Nutrition and Epidemiology, School of Public
Health, University of North Carolina, Chapel Hill, NC.
Reprint requests to Dr. Aaron R. Folsom, Division of Epidemiology, School of Public Health, University of Minnesota, Suite 300,
1300 South Second Street, Minneapolis, MN 55454-1015.
To study these issues further, we analyzed the relation of anthropometric variables with CHD incidence
in a biethnic cohort of middle-aged adults. We hypothesized that a relative preponderance of abdominal fat,
as measured by greater waist/hip ratio, would be a risk
factor for CHD in both African Americans and whites.
MATERIALS AND METHODS
Study population
The Atherosclerosis Risk in Communities (ARIC)
Study (20) is a multicenter prospective investigation
of atherosclerotic diseases. One aspect of the study
includes examination and follow-up of a biethnic,
population-based cohort of those aged 45-64 years
from Forsyth County, North Carolina; Jackson, Mississippi (African Americans only); the northwest suburbs of Minneapolis, Minnesota; and Washington
County, Maryland.
A baseline home interview in 1987 through 1989
assessed participants' health behaviors, sociodemographic characteristics, and disease histories. A clinic
examination included measurements of cardiovascular
disease risk factors, a 12-lead electrocardiogram, and a
B-mode ultrasound examination of selected arterial
sites. Approximately 46 percent of those who were
eligible in Jackson and 65 percent in the other three
communities completed the clinic visit, yielding a total
1187
1188
Folsom et al.
of 15,792 participants. A previous report described the
participants (21). The ARIC Study reexamined participants in 1990-1992 (93 percent return rate) and
1993-1995 (86 percent return rate).
Baseline measurements
Technicians measured height to the nearest centimeter and weight to the nearest pound with participants in
scrub suits and without shoes. We calculated body
mass index (BMI) (kg/m2). Technicians measured circumferences of the waist (umbilical level) and hip
(maximum buttocks) to the nearest centimeter. We
calculated both waist/hip ratio and another measure of
central adiposity, the conicity index (C-index), which
is a height- and weight-standardized measure of abdominal girth (22). Each participant reported his or her
weight at age 25 years. We calculated BMI at age 25,
using height at baseline, and determined weight
change between age 25 and baseline.
Participants reported their smoking status and
amount smoked per day. They similarly reported their
drinking status and the amount of beer, wine, and
liquor usually drunk, which was converted to alcohol
intake per day. Women reported their menstrual history and were categorized as premenopausal (current
menstruation), perimenopausal (menstruation within
the past 2 years, but not currently), postmenopausal
(surgical or natural cessation of menstruation more
than 2 years ago), or unknown ovarian status. Women
also reported their current or past use of hormonal
replacement therapy.
We defined prevalent CHD at baseline, for exclusion, as a history of angina pectoris by the Rose
questionnaire (23), a self-reported history of a physiciandiagnosed heart attack, evidence of a prior myocardial
infarction by electrocardiogram, or a report of prior
cardiovascular surgery or coronary angioplasty. We
created a score for family history of CHD based on the
method described by Hunt et al. (24).
Ascertainment of incident events
The ARIC Study ascertained CHD incidence by
several methods (20, 25). Interviewers contacted participants annually by telephone to identify all hospitalizations and deaths. The ARIC Study staff also
surveyed death certificates and discharge lists from
local hospitals to detect additional deaths and cardiovascular events. For hospitalized patients, trained abstractors obtained the hospital chart and recorded the
presenting signs and symptoms, including chest pain,
cardiac enzymes, and related clinical information.
They photocopied up to three 12-lead electrocardiograms (the first, the last, and one on approximately the
third hospital day). Trained coders at the University of
Minnesota visually coded the electrocardiograms using the Minnesota Code (26) and evaluated wave-form
evolution using side-by-side comparisons. The ARIC
Study investigated out-of-hospital deaths (25) by
means of death certificates, interviews with next of kin
(in approximately 81 percent of cases), and questionnaires completed by the patient's physicians (in approximately 91 percent of the cases). We abstracted
coroner reports and autopsy reports, when available,
for use in validation.
We defined CHD incidence for this report as a
validated definite or probable myocardial infarction or
definite CHD death. Two members of the ARIC Morbidity and Mortality Classification Committee reviewed all potential clinical CHD events by using
published criteria (25), and the chair of the Committee
adjudicated differences between the two reviewers.
We defined unrecognized myocardial infarction by the
appearance between the first and subsequent ARIC
examinations of a major Q wave or a minor Q wave
with ischemic ST-T changes or a myocardial infarction by computerized NOVACODE (27) criteria, confirmed by side-by-side visual electrocardiogram comparison. We did not include coronary revascularization
in the definition of CHD because we were concerned
about differential use of procedures by race, sex,
and/or obesity status.
Data analysis
Of the 15,792 ARIC participants, 14,040 were free
of CHD at baseline. We used analysis of covariance to
compute sex-specific, age-, ethnicity-, and ARIC field
center-adjusted mean baseline values of the anthropometric variables for participants who did versus those
who did not develop an incident CHD event during
follow-up. When categorizing anthropometric variables, we used sex-specific quartile or tertile cutting
points because the distributions for men and women
were quite different. We used Poisson regression to
compute age-, ethnicity-, and field center-adjusted incidence rates. We computed length of follow-up for
clinically recognized cases as the time lapsed between
the baseline examination and the first CHD event.
Because we could not determine the exact date of an
unrecognized myocardial infarction, we arbitrarily assigned its occurrence as the midpoint between the
ARIC examination at which an electrocardiogram revealed it and the immediately prior examination. For
noncases, follow-up continued until the date of death,
the date of last contact (if lost), or else through December 31, 1994.
We computed adjusted relative risks of CHD in
relation to categorical, or continuous, anthropometric
Am J Epidemiol
Vol. 148, No. 12, 1998
Body Mass Index, Waist/Hip Ratio, and Coronary Disease
indices using proportional hazards regression. We
tested trends in relative risks across quartiles in regression models using a quartile variable coded 1 through
4. We chose to adjust in various models for age
(continuous), ethnicity (African American, white),
cigarette smoking (never, former, current; and packyears), alcohol intake status (never, former, current),
and family history of CHD (24) score ( < - 0 . 5 , -0.5
to 0.5, >0.5, or unknown). We tested five other covariates that proved not to be confounding factors of
the association between body size and incident CHD;
these were dropped because the number of events to
covariates was small. The covariates were ARIC field
center, education level (less than high school, high
school graduate, post-high school), grams of alcohol
per day, and, in women, menopausal status (pre-, peri-,
or postmenopausal, or unknown ovarian status), and
hormone replacement therapy (never, former, current).
Although the ARIC Study measured plasma lipids,
blood pressure, and serum glucose, we did not adjust
for these potential mediators of obesity effects, since
doing so would be overadjustment because of their
position on the causal pathway between obesity and
CHD (28).
RESULTS
In the ARIC Study cohort free of prevalent CHD at
baseline, 273 men and 125 women developed CHD
over an average of 6.2 years of follow-up.
Table 1 shows that men and women who developed
CHD had a higher average waist circumference, waist/
hip ratio, and C-index at baseline than did those who
remained free of CHD. In women, but not in men,
mean weight and BMI at baseline and BMI at age 25
also were higher in those who developed CHD versus
those who did not. Mean values of height, change
between weight reported at age 25 years and that
measured at baseline, and hip circumference were not
different (p > 0.05) in those who developed CHD
versus those who did not.
The C-index was highly correlated with waist/hip
ratio (r = 0.81) and waist circumference (r = 0.80),
and the waist circumference was highly correlated
with BMI (r = 0.88) and waist/hip ratio (r = 0.73).
Therefore, we focused most of our attention on waist/
hip ratio and BMI (which were correlated, r = 0.43).
Figure 1 shows that the age-, ethnicity-, and field
center-adjusted incidence rate of CHD increased at
least two-fold across quartiles of the waist/hip ratio in
both sexes. In contrast, the incidence rate increased
1.1-fold in men and 1.8-fold in women across quartiles
of BMI (figure 2).
Adjusted for potential confounders (table 2), the
relative risks of CHD overall rose 1.80-fold across
quartiles of waist/hip ratio in men (p for trend =
0.002) and 2.10-fold in women (p for trend = 0.008).
Modeled as a continuous variable, the relative risk of
CHD per 0.078 increment (1 standard deviation) of
waist/hip ratio was 1.44 in men and 1.32 in women
(both p < 0.01), and quadratic terms were not significant. For BMI, relative risks increased 1.31-fold
across quartiles in men {p for trend = 0.061) and
1.98-fold in women {p for trend = 0.015). Per 5.3
kg/m2 (1 standard deviation), relative risks were 1.11
in men (p = 0.16) and 1.22 in women (p = 0.011),
and quadratic terms were not significant. When waist/
hip ratio and BMI were both included as continuous
variables in sex-specific models, only waist/hip ratio
was statistically significant. Relative risks across quartiles of waist circumference increased 1.51-fold in
men (p for trend = 0.007) and 2.53-fold in women {p
for trend = 0.005) (not shown).
TABLE 1. Sex-specific, age-, ethnicity-, and center-adjusted mean values of anthropometric variables in
participants who did versus those who did not develop CHDt in ARIC,t 1987-1994
Incident CHD
Variable
Height (cm)
Weight (kg)
BMIf (kg/m2)
BMI at age 25 (kg/m2)
Weight change (kg)
Waist circumference (cm)
Hip circumference (cm)
Waist/hip ratio
C-index
Approximate
SDf
9.3
16.7
5.3
3.7
13.0
13.9
10.4
0.078
0.09
Women
Men
Yes
(n = 273)
176.5
86.1
27.6
24.4
10.0
100.4
102.8
0.975
1.32
No
(n = 5,915)
176.2
85.2
27.4
24.2
10.1
98.7*
102.7
0.960*
1.31*
Yes
(n=125)
No
(n = 7,727)
162.1
76.4
29.1
23.4
14.6
99.3
107.6
0.922
1.33
162.3
73.2*
27.7*
22.1*
14.9
94.9*
105.9
0.893*
1.30*
* p < 0.05 for sex-specific difference between incident cases and noncases.
t CHD, coronary heart disease; ARIC, Atherosclerosis Risk in Communities; SD, standard deviation; BMI, body
mass index.
Am J Epidemiol
Vol. 148, No. 12, 1998
1189
1190
Folsometal.
Men
0.93
0.96
Women
0.99
0.83
0.89
0.95
Quartile of Waist-to-Hip Ratio
FIGURE 1. Sex-specific age-, ethnicity-, and field center-adjusted incidence of coronary heart disease according to quartiies of waist/hip
ratio, the ARIC Study, 1987-1994.
Men
24.7
26.9
Women
29.7
23.3
26.6
31.1
Quartile of Body Mass Index (kg/m 2 )
FIGURE 2. Sex-specific age-, ethnicity-, and field center-adjusted incidence of coronary heart disease according to quartiies of BMI, the
ARIC Study, 1987-1994.
In the quartile analysis, the associations of BMI with
CHD appeared generally similar in whites and African
Americans (table 2), and tests of BMI by ethnicity
interaction in continuous variable models were not
significant (p < 0.25). The association of waist/
hip ratio quartiies with CHD was equally strong in
African-American and white men, but appeared stronger in African-American than in white women. However, again a waist/hip ratio by ethnicity interaction
was not significant. Among the participants who had
never smoked, the magnitudes of the relative risks
were basically similar for waist/hip ratio and BMI (the
95 percent confidence intervals overlapped), but rela-
tive risks for nonsmokers were higher than those for
the overall cohort (suggesting that relative risks for the
overall cohort were affected by some residual confounding by smoking). Subgroup associations for
waist circumference and CHD (not shown) were similar to those for waist/hip ratio.
We also determined the joint relative risk of CHD
by tertiles of waist/hip ratio and those of BMI simultaneously (figure 3). Compared with those in the lowest tertiles of both variables and adjusted for the same
covariates as in table 2, the relative risk of CHD was
elevated most for those in the highest tertile of waist/
hip ratio who also had a BMI in the second tertile
Am J Epidemiol
Vol. 148, No. 12, 1998
Body Mass Index, Waist/Hip Ratio, and Coronary Disease
1191
TABLE 2. Sex-specific relative risks* (95% confidence intervals) of coronary heart disease in relation to quartiles of waist/hip
ratio and body mass index, ARICt Study, 1987-1994
Waist/hip ratio
Men
<0.925
Women
0.9250.961
0.9620.999
>1.00
p for trend
<0.835
0.8350.894
0.8950.954
>0.954
p for trend
Overall
No. of cases
RRt
95% Clt
45
1.0
49
1.06
0.7-1.6
77
1.70
1.2-2.5
92
1.80
1.2-2.6
0.002
14
1.0
21
1.13
0.6-2.2
32
1.57
0.8-3.0
53
2.10
1.1-3.8
0.008
African-American
No. of cases
RR
95% Cl
19
1.0
14
1.08
0.5-2.2
16
1.87
0.96-3.6
13
1.68
0.8-3.4
0.064
3
1.0
9
2.07
0.6-7.7
12
2.33
0.7-6.3
29
4.22
1.3-14
0.019
White
No. of cases
RR
95% Cl
26
1.0
35
1.07
0.6-1.8
61
1.67
1.1-2.6
79
1.82
1.2-2.8
0.002
11
1.0
12
0.87
0.4-2.0
20
1.39
0.7-2.9
24
1.43
0.7-3.0
0.194
Never smokers
No. of cases
RR
95% Cl
8
1.0
13
1.78
0.7-4.3
19
3.13
1.4-7.2
14
2.45
1.02-5.9
0.020
5
1.0
7
1.16
0.6-5.1
13
1.81
0.6-5.1
25
3.00
1.1-7.9
0.017
23.326.5
26.631.0
>31.0
BMIt (kg/m2)
Men
<24.7
Women
24.726.9
26.929.7
>29.7
p for trend
<23.3
p for trend
Overall
No. of cases
RR
95% Cl
64
1.0
56
0.99
0.7-1.4
71
1.24
0.9-1.8
73
1.31
0.9-1.8
0.061
21
1.0
24
1.11
0.6-2.0
29
1.27
0.7-2.3
44
1.98
1.1-3.4
0.015
African-American
No. of cases
RR
95% Cl
19
1.0
12
1.03
0.5-2.2
11
0.83
0.4-1.8
21
1.20
0.6-2.3
0.763
3
1.0
11
1.91
0.5-6.9
13
1.54
0.4-5.4
24
2.15
0.6-7.2
0.274
White
No. of cases
RR
95% Cl
45
1.0
44
0.98
0.6-1.5
60
1.36
0.9-2.0
52
1.33
0.9-2.0
0.069
18
1.0
13
0.87
0.4-1.8
16
1.30
0.7-2.6
20
2.28
1.2-4.4
0.007
Never smokers
No. of cases
RR
95% Cl
8
1.0
14
1.58
0.7-3.8
14
1.44
0.6-3.4
18
1.91
0.8-4.4
0.169
3
1.0
10
2.36
0.6-8.6
14
2.82
0.8-9.9
22
3.35
0.97-11.5
0.051
• Adjusted (except when stratified) for age, ethnicity, smoldng status and amount, alcohol drinking status, and family history of coronary heart disease,
t ARIC Atherosclerosis Risk In Communities; RR, relative risk; Cl, confidence Interval; BMI, body mass index.
(relative risk (RR) = 2.1, 95 percent confidence interval (CI) 1.4-3.2 for men; RR = 1.7, 95 percent CI
0.8-3.4 for women) or the third tertile (RR = 1.4, 95
percent CI 0.97-2.2 for men; RR = 1.8, 95 percent CI
0.9-3.4 for women) and for those in the highest tertile
of BMI who also had a waist/hip ratio in the second
tertile (RR = 1.5, 95 percent CI 0.9-2.4 for men;
RR = 1.6, 95 percent CI 0.8-3.6 for women).
DISCUSSION
This prospective study of middle-aged adults
showed overall that waist/hip ratio and BMI were both
moderately strongly associated with incident CHD in
women, whereas in men, waist/hip ratio showed a
Am J Epidemiol
Vol. 148, No. 12, 1998
somewhat stronger positive association with CHD
than did BMI. These associations between body size
were somewhat stronger among never smokers than in
the total cohort. This is consistent with the argument
made by Manson et al. (28) that smoking is such a
strong confounder of obesity-disease relations that it
should be examined among never smokers separately.
More uniquely, we found that the associations of BMI
and waist/hip ratio with CHD did not differ greatly
between African Americans and whites. Admittedly,
statistical power was sufficient to rule out only large
differences between ethnic groups.
Our ethnic-specific findings for CHD incidence differ from those of several previous reports based on
1192
Folsom et al.
MEN
Relative
Risk
2
BMI
Tertiies
Waist/Hip Ratio
Tertiies
WOMEN
Relative
Risk
1
BMI
Tertiies
Waist/Hip Ratio
Tnrti I ac-
FIGURE 3. Sex-specific relative risks of coronary heart disease adjusted for age, ethnicity, smoking status and amount, alcohol drinking
status, and family history of CHD according joint tertiies of BMI and waist/hip ratio, the ARIC Study, 1987-1994.
mortality in cohorts from the 1940s to 1960s. Researchers studying cohorts assembled in the early
1960s in Evans County, Georgia (6), and Charleston,
South Carolina (8), found little association of BMI, or
chest, abdominal, and arm circumferences with CHD
mortality among African-American women. In contrast, measures of obesity were associated positively
with CHD mortality in at least some subgroups of
white women (8, 9). In the Charleston cohort, BMI
was not associated with CHD mortality in white men,
but showed a U-shaped association in AfricanAmerican men (7). In the American Cancer Society
Prevention Study I, begun in 1959-1960, BMI was associated positively with CHD mortality in white women,
but there was no association in African-American
women (9). A study of male US Army veterans dis-
charged in 1946-1947 found a positive association of
BMI with cardiovascular mortality in African Americans, similar to that for whites (10). We previously
reported that odds ratios between BMI and CHD prevalence at baseline in the ARIC Study were approximately equal in African Americans and whites (29).
Differences in the ethnic-specific findings of these
studies versus the ARIC Study may relate to different
eras, in particular, because weight has increased markedly in recent years in the United States (30).
In the past 15 years, research has implicated abdominal visceral adiposity as the most hazardous to cardiovascular health. Yet, the number of prospective
studies of CHD in relation to waist/hip ratio is relatively small (12-15, 18). In most of these studies
(12-15), waist/hip ratio was positively associated with
Am J Epidemiol
Vol. 148, No. 12, 1998
Body Mass Index, Waist/Hip Ratio, and Coronary Disease
the occurrence of CHD more strongly than was BMI.
This was also true in three of four sex-ethnicity groups
in this study, reinforcing the hypothesis that a preponderance of abdominal fat is most risky.
Data for African Americans relating fat distribution
with cardiovascular disease risk are extremely limited.
In contrast to our results, the only previous prospective
study found a strong association between waist/hip
ratio and cardiovascular mortality in white men, but
not in African-American men (10). Gillum (19) created two fat distribution indices to approximate waist/
hip ratio and found them nonsignificantly higher in
prevalent CHD cases than in noncases in a US national
survey, with little ethnic heterogeneity apparent. The
ARIC Study found similarly elevated odds ratios for
prevalent CHD in relation to waist/hip ratio (odds ratio
range, 1.3-1.4) in African Americans and whites and
in men and women (29). Studies of fat distribution and
CHD risk factors do not show consistent differences
between African Americans and whites. For example,
the Coronary Artery Risk Development in Young
Adults (CARDIA) investigators reported similar associations between waist/hip ratio and metabolic CHD
risk factors in African Americans and whites (31). The
Insulin Resistance and Atherosclerosis Study found
that African Americans, Hispanics, and non-Hispanic
whites had a similar association of insulin sensitivity
with abdominal obesity, although the association of
fasting insulin with abdominal obesity was slightly
weaker in African Americans than in non-Hispanic
whites (32). Yet, Dowling and Pi-Sunyer (11) concluded that metabolic risk factors were less related to
waist/hip ratio, controlled for total body fatness, in
African Americans than in whites.
Strengths of this study include its carefully standardized measurements of anthropometry and CHD
incidence in population-based samples. Limitations
include the relatively short follow-up, yielding a modest number of events so far, and a narrow cohort age
range. In addition, waist/hip ratio only approximates
the distribution of adipose tissue. Other measures,
such as computerized tomography, magnetic resonance imaging, and dual energy x-ray absorptiometry,
can more accurately assess visceral adipose mass (33),
but these are impractical for field epidemiology. Others have argued that waist circumference, not waist/
hip ratio, should be used to assess these relations (34).
However, waist circumference is highly correlated
with (r = 0.88) and essentially reflects BMI, whereas
waist/hip ratio seems to capture additional predictive
information.
Regardless of which index of adiposity is most
predictive of CHD, concern is growing that the prevalence of obesity in the United States is rising markAm J Epidemiol
Vol. 148, No. 12, 1998
1193
edly (30). Moderate-to-severe obesity is a risk factor
not only for CHD, demonstrated once again in these
data, but also for other chronic diseases (1). Our data
do not suggest that African Americans are spared more
than whites from the CHD risks accompanying obesity. This observation is especially important because
in African Americans the prevalence of obesity (and,
thus, its attributable risk for CHD) is high. Clearly,
continued and more-effective population-wide efforts
to prevent and treat obesity are needed.
ACKNOWLEDGMENTS
The ARIC Study was funded by contracts N01-HC55015, N01-HC-55016, N01-HC-55018, NO1-HC-55O19,
N01-HC-55020, N01-HC-55021, and N01-HC-55022 from
the US National Heart, Lung, and Blood Institute.
The authors thank the following ARIC staff for important contributions: Phyllis Johnson, Marilyn Knowles, and
Catherine Paton from the University of North Carolina, Chapel
Hill, NC; Jeannette Bensen, Kay Burke, Wilhelmenia Cheeks,
and Revitha Cook from the University of North Carolina,
Forsyth County, NC; Agnes Hayes, Jane Johnson, Penney
Lowery, and Patricia Martin from the University of Mississippi
Medical Center, Jackson, MS; Nancy MacLennan, Gail
Murton, Linda Neal, and Marilyn Nelson from the University
of Minnesota, Minneapolis, MN; Holly Healy, Joel Hill,
Mary Hurt, and Joan Nelling from The Johns Hopkins University, Baltimore, MD; Valarie Stinson, Pam Pfile, Hoang
Pham, and Teri Trevino from the University of Texas Medical
School, Houston, TX; Wanda Alexander, Doris Harper,
Charles Rhodes, and Selma Soyal from the Atherosclerosis
Clinical Laboratory, Methodist Hospital, Houston, TX; Kathy
Joyce, Mary Lauffer, Suzanne Pillsbury, and Tiffany Robertson from the Ultrasound Reading Center, Bowman-Gray
School of Medicine, Winston-Salem, NC; and Doris Jones,
C. Robert Matherly, Margaret Misch, and Stephen Noga from
the ARIC Coordinating Center, University of North Carolina,
Chapel Hill, NC.
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