Clustering of health-related behaviors among early and mid-adolescents in Tuscany: results from a representative cross-sectional study.

Background: A huge amount of literature suggests that adolescents' health-related behaviors tend to occur in clusters, and the understanding of such behavioral clustering may have direct implications for the effective tailoring of health-promotion interventions. Despite the usefulness of analyzing clustering, Italian data on this topic are scant. This study aimed to evaluate the clustering patterns of health-related behaviors. Methods: The present study is based on data from the Health Behaviors in School-aged Children (HBSC) study conducted in Tuscany in 2010, which involved 3291 11-, 13- and 15-year olds. To aggregate students' data on 22 health-related behaviors, factor analysis and subsequent cluster analysis were performed. Results: Factor analysis revealed eight factors, which were dubbed in accordance with their main traits: 'Alcohol drinking', 'Smoking', 'Physical activity', 'Screen time', 'Signs & symptoms', 'Healthy eating', 'Violence' and 'Sweet tooth'. These factors explained 67% of variance and underwent cluster analysis. A six-cluster κ-means solution was established with a 93.8% level of classification validity. The between-cluster differences in both mean age and gender distribution were highly statistically significant. Conclusions: Health-compromising behaviors are common among Tuscan teens and occur in distinct clusters. These results may be used by schools, health-promotion authorities and other stakeholders to design and implement tailored preventive interventions in Tuscany.

Trends in adolescent overweight prevalence in Italy according to socioeconomic position.

BACKGROUND: The aim of this research is to update the trend in overweight (including obesity) prevalence among Italian adolescents, evaluating possible differences by age and gender, and analyzing their relationships with socioeconomic status, between 2002 and 2014. METHODS: The present study is based on data from the Italian HBSC study at four time points (2002, 2006, 2010 and 2014), which involved 15 035 adolescents, aged 11-13-15 (7540 boys and 7495 girls). RESULTS: Gender and age were associated with the occurrence of overweight. In all surveys, boys had a higher prevalence of excess weight compared to girls (p < 0.001), but only among girls there was a significant increasing trend (from 11.2% in 2002 to 13.3% in 2014). From 2002 to 2014, the risk of being overweight was inversely associated with the economic level of the family, for both genders and all age groups. CONCLUSIONS: Data collected between 2002 and 2014 in Italy showed a low overall increase in prevalence of obesity and overweight and an inverse association between SES and obesity in all age groups and in both genders. These findings suggest that concerted, multi-sectorial, efforts are needed in Italy, in combination with a sound political will, focused on reducing social inequality associate.

Validity of self-reported height and weight for estimating prevalence of overweight among Estonian adolescents: the Health Behaviour in School-aged Children study.

BACKGROUND: Low to moderate agreement between self-reported and directly measured anthropometry is shown in studies for adults and children. However, this issue needs further evaluation during puberty, a period marked by several transitions. We examined the correspondence of BMI status based on self-reported versus measured anthropometric data among Estonian adolescents with a specific focus on gender and age differences. METHODS: Self-reported height and weight were determined in a national representative sample of Estonian schoolchildren collected within the framework of the HBSC (health behaviour of school-aged children) survey. Self-reported and directly measured height and weight were collected from 3379 students (1071 aged 11, 1133 aged 13 and 1175 aged 15 years). The standardized HBSC questionnaire was used for collecting self-reported data; direct anthropometric measures were taken after the HBSC questionnaires were completed. The accuracy of the self-reported values by age and gender groups were determined by comparing mean differences, Bland-Altman plots with limits of agreement, Kappa statistics, and by estimation of the sensitivity and positive predictive value for detecting overweight. RESULTS: Mean self-reported weight, height and body mass index (BMI) values were significantly lower than corresponding values obtained using direct measurements. Mean differences between self-reported and directly measured weight, height and BMI were largest among 11-year-olds and smallest among students aged 15 years. Underestimation of overweight prevalence (includes obese) showed a graded trend which decreased in older age groups; the difference was greater among girls than boys in all age groups. The mean underestimation of overweight prevalence based on self-reported anthropometry was 3.6 percentage points. The positive predictive value was 72.3 % for boys and 63.4 % for girls. CONCLUSION: A distinct age-related pattern in underestimation of weight, height and prevalence of overweight was found; the bias decreased with increasing age. The mean underestimation of overweight prevalence based on self-reports was small, 3.6 %. Self-reported height and weight remain the method of choice in large surveys for practical and logistical reasons.

Trends in overweight and obesity prevalence in Tuscan schoolchildren (2002-2012).

OBJECTIVE: The aim of the present study was to examine the prevalence and time trends in childhood overweight including obesity and obesity among Tuscan children from 2002 to 2012. DESIGN: Cross-sectional study at five time points (Tuscan Nutritional Surveillance Surveys conducted in the years of 2002, 2006, 2008, 2010 and 2012). Trained personnel directly measured the height and weight of the subjects. BMI was assessed by means of the International Obesity Task Force (IOTF) and WHO cut-offs. SETTING: Representative sample of children in the Tuscany region (Italy). SUBJECTS: Children (n 7183) aged between 7·5 and 9·5 years (3711 boys and 3472 girls). RESULTS: With respect to the estimation of the absolute prevalence level of childhood overweight, a discrepancy was observed between the two criteria. In all surveys, more boys than girls were overweight (including obesity). Trend analysis showed a significant decrease in the prevalence of overweight including obesity and obesity in Tuscan children from 2002 to 2012 (32·0 % v. 25·8 %, P<0·001 on using IOTF criteria and 37·7 % v. 34·3 %, P<0·001 on using WHO criteria for overweight including obesity; and 10·0 % v. 6·7 %, P<0·001 on using IOTF criteria and 12·5 % v. 11·3 %, P=0·035 on using WHO criteria for obesity). CONCLUSIONS: The present study is the first report from an Italian region showing a significant decrease in childhood obesity and overweight in the last 10 years. This reduction is probably a result of regional and local actions that have taken place in many sectors of society. However, efforts should be made to lower the prevalence of childhood obesity and overweight further.

Fruit and vegetable consumption trends among adolescents from 2002 to 2010 in 33 countries.

BACKGROUND: Fruit and vegetable consumption is linked to many positive health outcomes, nevertheless many adolescents do not consume fruit and vegetables on a daily basis. METHODS: Data of 488,951 adolescents, aged 11-, 13- and 15- years, from 33 mainly European and North American countries/regions participating in the cross-sectional Health Behaviour in School-aged Children surveys in 2002, 2006 and 2010, were used to investigate trends in daily fruit and vegetable consumption between 2002 and 2010. RESULTS: Multilevel logistic regression analyses showed an increase in daily fruit and vegetable consumption between 2002 and 2010 in the majority of countries for both genders and all three age groups. A decrease in consumption was noticed in five countries for fruit and five countries for vegetables. CONCLUSION: Overall, a positive trend was noticed, however increases in daily fruit and vegetable consumption are still indicated.

Factors associated with unhealthy behaviours and health outcomes: a cross-sectional study among Tuscan adolescents (Italy).

BACKGROUND: We aimed to determine the extent to which three core variables (school environment, peer group and family affluence) were associated with unhealthy behaviours and health outcomes among Tuscan adolescents. The unhealthy behaviours considered were smoking, alcohol consumption, sedentary lifestyle and irregular breakfast consumption; health outcomes were classified as self-reported health, multiple health complaints and life satisfaction. School environment was measured in terms of liking school, school pressure, academic achievement and classmate support; peer groups were evaluated in terms of the number of peers and frequency of peer contact. Family affluence was measured on a socioeconomic scale. METHODS: Data were taken from the Tuscan 2009/10 survey of "Health Behaviour in School-aged Children", a WHO cross-national survey. A binary logistic multiple regression (95% confidence intervals) was implemented. RESULTS: The total sample comprised 3291 school students: 1135 11-year-olds, 1255 13-year-olds and 901 15-year-olds. Peer group and school environment were associated with unhealthy behaviours such as smoking, alcohol consumption and sedentary lifestyle. Family affluence proved to have less impact on unhealthy behaviours, except in the case of adolescents living in low-income families. Poor health outcomes were directly related to a negative school environment. Regarding the influence of family affluence, the results showed higher odds of life dissatisfaction and poor self-reported health status in medium-income families, while low-income families had higher odds only with regard to life dissatisfaction. A consistent pattern of gender differences was found in terms of both unhealthy behaviours and health outcomes. CONCLUSIONS: Unhealthy behaviours are strongly related to the school environment and peer group. A negative school environment proved to have the strongest relation with poor health outcomes.

Overweight among students aged 11-15 years and its relationship with breakfast, area of residence and parents' education: results from the Italian HBSC 2010 cross-sectional study.

BACKGROUND: The international increase in overweight and obesity among children and adolescents over the past three decades confirms that childhood obesity is a global 'epidemic'. The World Health Organization considers childhood obesity to be a major public health concern. Childhood obesity is associated with cardiovascular, endocrine, musculoskeletal and gastrointestinal complications, and may have psycho-social consequences. The aim of this paper is to examine overweight (including obesity) prevalence and its association with geographic area of residence, parental education and daily breakfast consumption in Italian students aged 11-15 yrs. METHODS: A nationally representative sample of 11-15 year old students from 20 Italian Regions (Italian Health Behaviour in School-aged Children 2010-HBSC) was randomly selected (2,504 schools and 77,113 students). Self-reported anonymous questionnaires, prepared by the international HBSC network, were used to collect the data. BMI was calculated using self-reported weight and height and the International Obesity Task Force cut-offs. Multiple logistic regressions were performed to assess the relationship between the risk of overweight and parental education, area of residence and breakfast consumption in each age group and gender. RESULTS: Boys were more likely to be overweight or obese than girls (28.1% vs. 18.9% at 11 yrs-old, 24.8% vs. 16.5% at 13 yrs and 25.4 vs. 11.8% at 15 yrs). The prevalence of overweight and obesity was lower among the older girls. Overweight and obesity rates increased from the North of Italy to the South in both boys and girls and in all age groups. Boys 11-15 yrs living in southern Italy had an OR=2.05 (1.77-2.38) and girls 2.04 (95% CI 1.70-2.44) for overweight (including obesity) compared with those living in the North. Parent's low educational level and no daily breakfast consumption were also associated with overweight including obesity (p<0.05). CONCLUSION: The prevalence of obesity and overweight in Italian school-children 11-15 yrs old are high, in particular in the South and in boys. These findings suggest appropriate interventions are needed, at the community as well as the individual level, in particular in the southern regions. However, more research is warranted on intermediary factors to determine which interventions are likely to be most effective.

Trends in thinness prevalence among adolescents in ten European countries and the USA (1998-2006): a cross-sectional survey.

OBJECTIVE: To describe the prevalence of 'graded thinness' in children aged 11, 13 and 15 years in eleven developed countries and to identify trends in the prevalence of 'thinness' (BMI < 17 kg/m2 at age 18 years) by age and gender. DESIGN: Cross-sectional study using data collected through self-reported questionnaires. SETTING: Data were taken from the 1997/1998, 2001/2002 and 2005/2006 surveys of the Health Behaviours in School-aged Children (HBSC) Study. SUBJECTS: Children and adolescents from ten European countries and the USA (n 158 000). RESULTS: Prevalence of grades 1, 2 and 3 of thinness was higher among 11-year-old students compared with the 13- and 15-year-olds in all countries. A higher prevalence of thinness was observed in girls than in boys. Since 1998 the prevalence of thinness decreased steadily in Czech boys and girls, while it increased for French girls. In the total European sample of females, thinness decreased from 1998 to 2006 (χ 2 for trend, P < 0·01). Age-adjusted logistic regression analysis showed that Czech boys and girls, and Flemish and American girls were less likely to be thin in 2006 than in 1998; while a noteworthy increment, even if borderline significant, was observed for French girls with a 41% increase in the likelihood to be thin. CONCLUSIONS: Our findings suggest that thinness is an important overlooked phenomenon with wide variation in prevalence and trends across developed countries. It deserves further longitudinal studies in a multinational context that could increase the understanding of the factors associated with thinness and contribute to developing preventive and nutritional programmes targeted at controlling obesity and chronic diseases, while monitoring thinness.

Association between fruits and vegetables intake and frequency of breakfast and snacks consumption: a cross-sectional study.

BACKGROUND: There are very few studies on the frequency of breakfast and snack consumption and its relation to fruit and vegetable intake. This study aims to fill that gap by exploring the relation between irregular breakfast habits and snack consumption and fruit and vegetable intake in Tuscan adolescents. Separate analyses were conducted with an emphasis on the potentially modifying factors of sex and age. METHODS: Data was obtained from the 2010 Tuscan sample of the Health Behaviour in School-aged Children (HBSC) study. The HBSC study is a cross-sectional survey of 11-, 13- and 15-year-old students (n = 3291), selected from a random sample of schools. Multivariate logistic regression was used for analyzing the food-frequency questionnaire. RESULTS: A significant relation was found between low fruit and vegetable intake and irregular breakfast habits. Similarly, low fruit intake was associated with irregular snack consumption, whereas vegetable intake did not prove to be directly related to irregular snack consumption. Different patterns emerged when gender and age were considered as modifying factors in the analyses. A statistically significant relation emerged only among female students for irregular breakfast habits and fruit and vegetable intake. Generally, older female participants with irregular breakfast habits demonstrated a higher risk of low fruit and vegetable intake. Age pattern varied between genders, and between fruit and vegetable consumption. CONCLUSIONS: Results suggest that for those adolescents who have an irregular consumption of breakfast and snacks, fruit intake occurs with a lower frequency. Lower vegetable consumption was associated with irregular breakfast consumption. Gender and age were shown to be moderators and this indicated the importance of analyzing fruit and vegetable intake and meal types separately. This study also confirmed that health-promotion campaigns that aim to promote regular meal consumption and consumption of fruits and vegetables need to take into account gender and age differences in designing promotional strategies. Future research should identify evidence-based interventions to facilitate the achievement of the Italian guidelines for a healthy diet for fruit, vegetables and meals intake.

Diet and physical activity in pre-school children: a pilot project for surveillance in three regions of Italy.

OBJECTIVE: To test a surveillance system on diet and physical activity based on data gathered at well-child visits. DESIGN: Cross-sectional data collection on growth, diet, physical activity and sociodemographic variables. SETTING: Offices of 179 paediatricians in three Italian regions. SUBJECTS: 26 898 children for a total of 32 915 well-child visits at 1, 3, 5-6, 8-9, 12, 18, 24, 36 and 60-72 months of age. RESULTS: The BMI Z-score was lower than the WHO standard at 1 and 3 months but higher from 8-9 months onwards. The rates of breast-feeding at 1, 3, 5-6, 8-9 and 12 months were 88 %, 75 %, 64 %, 52 % and 32 %, respectively, with 5 % and 3 % continuing up to 24 and 36 months. Exclusive breast-feeding was 64 %, 54 % and 20 % at 1, 3 and 5-6 months, respectively; 57 % at 5 months and 85 % at 6 months were given complementary foods. Only 8 % and 10 % of children were taking five portions of fruit and vegetables daily, while 47 % and 51 % were consuming sugar-sweetened beverages at 36 and 60-72 months, respectively. At 60-72 months, less than 10 % reported at least 1 h of moderate-to-vigorous physical activity on 5-7 d/week, and 32 % watched television or played videogames for more than 2 h/d, every day. The majority of paediatricians rated the surveillance system as reliable and feasible. CONCLUSIONS: Surveillance for diet and physical activity in pre-school children, with data gathered during well-child visits, is feasible and potentially useful to plan and evaluate activities for the prevention of obesity.

Ecological study of isolation and suicide in Tuscany (Italy).

The purpose of the study was to investigate the association between suicide and demographic and socio-economic measures in Tuscany. Data on standardized rates of suicide from 1997 to 2005 in addition to census-derived variables, income and abstention were derived from the Mortality register, the 2001 Census, the Tax Agency and the Regional Electoral Office databases. Pearson's correlation and stepwise multiple regression analyses (unweighted and weighted by population) were used to analyze the association between suicide rates and demographic and socio-economic measures for the 34 health districts for both males and females. The correlation analyses showed that suicide was significantly associated with many variables in men, but only with old age in women. The multiple regression analyses showed that the best predictors in men were education, single person households and isolated houses (only education and single person households in the weighted model). For women, the best predictors were the proportion of elderly people and income (this was also true for the weighted model, but in the opposite order). An ecological correlation between suicide and measures of economic deprivation and social fragmentation was found in both men and women. Among the best predictors, isolated houses may act as a marker for remoteness and isolation on a small scale.

Relationship between 8/9-yr-old school children BMI, parents' BMI and educational level: a cross sectional survey.

BACKGROUND: Parents are responsible not only for the genetic structure of their children, but also for passing onto them their behaviours and attitudes toward life. The aim of this study was to analyse the connection between school-age children's obesity and that of their parents as well as between child obesity and parents' educational level, as a proxy indicator of the socio-economic status (SES) of families in Tuscany. METHODS: The children sample was selected from "OKkio alla Salute 2010" (a cross sectional survey carried out by the Italian Institute of Health) and consisted of 1,751 (922 males and 855 females) 8-9 year-old school children. Weight and height were measured by ad hoc trained personnel, and Body Mass Index (BMI) categories were calculated using Cole et al.'s cut-off. Parents' weight, height and educational level were collected by a self-administered questionnaire. The educational levels were classified as high, medium and low. RESULTS: The prevalence of obese children increased along the parents' BMI category: from 1.4% for underweight mothers to 30.3% for obese mothers and from 4% for under-normal-weight fathers to 23.9% for obese fathers (p < 0.001). An inverse relationship was observed between the parents' educational level and child obesity, the lowest educational level corresponding to the highest prevalence of obese children: 9.3% for mothers with a low educational level compared to 5.8% for mothers with a high educational level (p = 0.15); similarly, the corresponding prevalence for fathers was 9.5% compared to 4.5% (p = 0.03). CONCLUSION: Parents' obesity and the cultural resources of the family, particularly the father's, seem to influence the prevalence of overweight and obesity in Tuscan children.

High temperatures and health outcomes: a review of the literature.

AIMS: To analyse the relationship between high temperatures and population health impacts, in terms of mortality and morbidity. METHODS: A literature search was conducted using Medline to collect data from studies on heat waves, temperature-health impacts curve, risk factors, and preventive measures. All the data collected was published in English and available up to December 2009. RESULTS: Numerous studies carried out in Europe following the 2003 heat wave, as well as those conducted prior to this date in Europe and North America, showed an increase in heat wave-related excess mortality. Recent studies have demonstrated that a forward shift of deaths may only explain a very limited quantity of the excess mortality observed (up to 15%) during major heat waves. Moreover, the results seem to exclude that ozone acts as a confounding variable, whilst it remains a potential effect modifier. CONCLUSIONS: Future research needs to explore the consistency of results in new settings, to quantify the burden of heat-related morbidity and in particular to evaluate the effectiveness of the implemented preventive measures.

Overweight in school-aged children and its relationship with demographic and lifestyle factors: results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) study.

OBJECTIVES: To examine overweight prevalence and its association with demographic and lifestyle factors in 11-15 year olds in the HBSC 2005-2006 survey. METHODS: Self-reports of height, weight, eating patterns, physical activity and sedentary behaviours were obtained from nationally representative samples in 41 countries (n=204,534). RESULTS: Overweight prevalence was highest in USA (28.8 %) and lowest in Latvia (7.6 %). In most countries, overweight was more prevalent in boys than girls. Overweight was consistently negatively associated with breakfast consumption and moderate to vigorous physical activity; OR range: 0.48-0.79 and 0.50-0.78, respectively. CONCLUSION: Overweight prevalence in youth remained high across the countries examined. The primary factors linked to overweight were breakfast consumption and physical activity. These data should contribute to formulating preventive programs and policies.

Socioeconomic effects on meeting physical activity guidelines: comparisons among 32 countries.

PURPOSE: This study examined the relationship between age and gender with physical activity (PA) and how meeting of PA guidelines (PAGL) is related to socioeconomic status (SES) and sedentary behaviors (SB). METHODS: Data were collected from 11-, 13-, and 15-yr-old students in 32 countries participating in the Health Behaviour in School-aged Children (HBSC) survey 2001/2002. A self-completed questionnaire assessed weekly moderate-to-vigorous physical activity (MVPA) and SB for the past 7 d and MVPA for a typical week. SES was assessed using the Family Affluence Scale (FAS). RESULTS: None of the countries averaged enough MVPA to meet PAGL. The pattern of MVPA across age and gender was consistent among all countries. In all countries, older children were less active when compared with the youngest children; girls were significantly less active than boys were (mean hours per week of MVPA 3.52 +/- 1.88 vs 4.13 +/- 1.95) and were more likely to not meet the PAGL. SES was significantly associated with the amount of reported MVPA. SES and PAGL were not significantly related in seven countries, and a significant decrease in the influence of age was observed in these countries compared with other countries. CONCLUSIONS: Levels of MVPA during adolescence showed consistent patterns across countries in relation to age, gender, and social class. The limited effect of age on PA in countries where the influence of social class was less strong suggests the possibility of a moderating effect of context in the development of habits acquired during childhood.

Comparison of a short food-frequency questionnaire and derived indices with a seven-day diet record in Belgian and Italian children.

OBJECTIVES: To compare food group intakes and dietary indices estimated from a 14-item food frequency questionnaire (FFQ) with a seven day diet record. METHODS: 112 Belgian and 114 Italian children (11-12 years) completed the FFQ followed by a seven-day diary (FD) and a retest one week later. Dietary indices were calculated from the FFQ and the FD. RESULTS: Spearman's correlations between the FFQ items and the diary varied between -0.13 and 0.67. When comparing the FFQ with the FD an overestimation was found for most items. The Excess Index was significantly correlated with energy intake (respectively 0.35 and 0.25 for Belgian and Italian children); the Variety Index with fiber intake (0.26 for both) and Calcium intake (respectively 0.32 and 0.41); the Fiber Index with fiber intake (respectively 0.30 and 0.37) and the Calcium Index with Calcium intake (respectively 0.47 and 0.50). CONCLUSION: When the FFQ is used for estimating consumption frequencies, overestimation must be considered. The ability to rank individuals varies considerably between food items. The Calcium index can be useful in situations requiring brief dietary instruments. The value of the other indices is lower although still associations in the expected directions were found.

[Health effects of heat waves]. / Effetti sulla salute delle ondate di calore.

Climate change, characterized by increased mean temperatures and more frequent occurrence of extreme temperatures, may lead to adverse health effects through different and complex mechanisms due to substantial changes in the physical and social environment. The most easily measurable health effects of climate change in high-risk groups are the direct effects of excessively high temperatures. A literature review was performed to identify studies regarding heat waves, risk factors and prevention programmes. A large number of studies performed in Europe during the August 2003 heat wave, and previously in both Europe and North America, showed excess mortality during periods of extreme heat. The role of pollution as a confounding factor remains dubious. Groups at risk include the elderly, the urban population, individuals with impaired health and those with low income. Aging of the population (especially in industrialised nations) and increased urbanization (especially in developing countries) may further increase ill health effects of high temperatures.

[The descriptive epidemiology of suicide in Tuscany, 1988-2002]. / Epidemiologia descrittiva del suicidio in Toscana, 1988-2002.

AIMS: To describe the epidemiology of Suicide in Tuscany according to the triad of time, place and person. METHODS: The 4,764 cases of suicide, defined according to categories E950-E959 of ICD-9 in Tuscany over the period 1988-2002, were obtained from the Tuscan Mortality Register. Mortality indicators were calculated and analyzed. The spatial analysis was carried out by deriving Empirical Bayes Estimates for the 287 municipalities. RESULTS: The crude mortality rate in the 2000-2002 is 7.8 per 100000 population (male: 12.4; female: 3.5). The age-standardized rate in the 2000-2002 is 5.8 per 100,000 population (male: 9.6; female: 2.6). The highest risk for suicide, especially in the case of males, are concentrated in the southern hinterland Tuscany, in a cluster of rural municipalities that represent the old mining district of Tuscany. The SMRs according to residential municipality (population per square kilometre), confirm a greater risk of suicide for males residing in rural communities. CONCLUSIONS: The cluster of excessive mortality from suicide in Southern Tuscany could be the consequence of social determinants, related to the urban and social crisis following agriculture decline and mine closure.

Carpal tunnel syndrome incidence in a general population.

OBJECTIVE: To determine the incidence of carpal tunnel syndrome (CTS) in a general population of a restricted area in the middle part of Italy. METHODS: Prospective study to identify cases of CTS, newly diagnosed on the basis of clinical symptoms and delay in distal conduction velocity of the median nerve. In the 8-year period from 1991 to 1998, cases were identified by electromyographic services in the Siena area of Local Health District No. 7 of Tuscany (Italy). This area has a population of 120,000. RESULTS: In the 8-year period, 3,142 cases (79.7% women and 20.3% men; mean age, 55 years; range, 13 to 97 years) were identified. The mean annual crude incidence was 329 cases per 100,000 person-years, and the standardized incidence was 276. The sex-specific incidences were 139 for men and 506 for women. The mean annual incidence for men increased moderately but significantly during the study period, whereas that for women remained constant. The age-specific incidence for women increased gradually with age, reaching a peak between 50 and 59 years, after which it declined. In men, there was a bimodal distribution with peaks between 50 and 59 years and between 70 and 79 years. Rural and industrial areas had higher crude and age- and sex-specific incidences than did urban areas. CONCLUSIONS: The incidence in the Siena area is about threefold that reported in the Rochester area (Minnesota) and is similar to that of Marshfield (Wisconsin). The different results with respect to US reports may depend on case inclusion criteria and occupational activities of the population at risk.