© 1991 S. Karger AG. Basel 0250-6807/91/03 57-0064$ 2.7 5/0
Ann Nutr Metab 1991;3S(suppl I ):64—68
Health in Central Europe Felix Gutzwiller Institute of Social and Preventive Medicine, University of Zurich. Switzerland
Key Words. Central Europe • Cancer of colon • Cardiovascular disease • Diet • MONICA study
Introduction The evaluation of health has been an im portant preoccupation of many government agencies and researchers in Europe over the last decade. Health, evaluated convention ally as the absence of ill health, can be expressed as level of risk, morbidity (inci dence and prevalence) and mortality within a given population. Good comparative data on risk are now forthcoming, e.g. within the framework of the international MONICA study, or other epidemiological surveys. In some countries, in the last few years, there has been a development towards national health surveys, including nutritional sur veys, with the aim of monitoring risk and morbidity over time. However, comparative and reliable data on the incidence of major
disease categories are only available in the field of cancer. Mortality statistics are on a reasonably good level in most central Euro pean countries. Still, cross-comparative re search on the validity of comparisons is needed. Of course, it is an impossible under taking to summarize the health patterns of all 11 central European countries. This paper therefore concentrates on two examples of two major disease groups: cancer of the in testines (chiefly colon and rectum), and heart disease (chiefly, coronary heart dis ease, CHD). For both diseases, there is strong evidence of a relationship to dietary fat intake. The overall evidence as summa rized in table 1 is clearly stronger for CHD and dietary fat intake, including experimen tal evidence of changes in disease incidence with changes in dietary fat intake [1, 2],
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
Abstract. Some of the 11 central European countries enjoy today a high level of health, among the highest life expectancies worldwide and. concomitantly, low or intermediate risk factor levels for some of the major chronic diseases. However, on a regional level, and particularly according to social groups, important differences in risk, morbidity and mortal ity still remain. Perhaps the most dramatic differences now found relate to east-west differ ences within Europe. This paper addresses these issues drawing upon examples such as cancer of the colon and coronary heart disease.
Health in Central Europe
30 i
i
65
20 l
t
10 i
10 i
i
l
l
20 i
30 l
l
Fig. I. Average age-standardized (world) mortality rates for cancer of the intestines per 100.000 in Euro pean countries. 1978-1982.
Cancer of the Colon According to a recently published over view. countries with the highest cancer mor tality rates (all sites, males), in 1978-1982, in Europe were Belgium, Czechoslovakia, and Hungary. For females (all sites) the high est rates were in Scotland, Denmark, and Hungary [3]. In general, there is a clear ten dency for southern Europe to have low can cer rates (both for mortality and incidence)
Table 1. Dietary fat. colon cancer and CHD Evidence
Colon cancer
CHD
Animal experiments
+
++
International correlation
++
++
Case control studies
+, h
+
Prospective cohort studies
(+)
++
Experimental
-
+
while central Europe and Scotland were in the upper part of the distribution. Figure 1 presents the age-standardized mortality rates for cancer of the intestines, grouping both colon and rectum cancers for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
After a presentation of the disease pat terns this paper will go on to show how, with an international study protocol, risk factors can be monitored cross-culturally, in order to better understand the variation in the dis ease pattern between countries.
66
Gutzwiller
200
100
100
200
300
400
500
600
Scotland Northern Ireland Finland Czechoslovakia Ireland (84) Hungary England & Wales Norway Denmark Poland Sweden Netherlands FRG Austria Belgium (84) Yugoslavia (83) Italy (83) Switzerland Portugal Spam (81) France
]
Fig. 2. Death rates for heart disease and CHD by sex, ages 45-64, in 27 countries, 1985.
Coronary Heart Disease The highest rates for heart disease within Europe are still in the English speaking and Nordic areas (fig. 2) [4], Within central Eu rope. it is the eastern European countries that have particularly high rates. In addition, even in countries with traditionally low mor tality rates (such as Yugoslavia), these rates are rising. Females have only a fourth or third of the rates of males. Even within cen tral Europe, there are still remarkable differ ences: e.g. even between neighboring coun tries such as France and the FRG.
Reasons for Change: Studies of Mortality Trends For some years now, descriptive risk fac tor data are also available for Europe [5]. A large comparison of European risk factors found for cholesterol that mean values were well above the now accepted ideal of 200 mg/dl. The diminishing values found in the ERICA project from north-west to south east correspond to expectations, although the difference between east and south was nonexistent in men [5], However, still not enough is known about the mechanism by which mortality rates change. To help understand these changes, WHO started a major international collaborative study to monitor the trends and determi nants in cardiovascular disease (MONICA) over a 10-year period within many different populations. The project will provide data on mortality from CHD and incidence of
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
better comparability. Again, some central European countries rank rather high: in fact, Luxembourg tops the mortality statistics. Male and female rates are quite comparable, and there is about a 2-fold difference within central European countries.
67
Health in Central Europe
First Results
In the WHO MONICA project, risk fac tors are monitored through three (two in some populations) independent cross-sec tional population surveys. Although the main objective is to evaluate risk factor trends, the adoption of a standard methodol ogy for the surveys across the MONICA col laborating centers makes it possible to com pare cross-sectional data collected from dif ferent MONICA populations. These results are from the first cross-sectional analysis of levels of the main risk factors in the popula tions studied in the WHO MONICA project at the beginning of the study. In the MONICA study, the smallest pop ulation groups for which data on risk factors are collected are called ‘reporting units’. The sampling strategy was to have representative probability samples within each sex and 10year age group, at least for the age range 3564 years. For the collaborating centers, the
minimal sample size was 200 persons for each sex and 10-year age group. About half of the centers used simple random sampling or systematic random sampling. In the rest of the centers multistage sampling was used. The participation rate achieved varied from 54 to 89%. As a general rule, data were not included in the present analysis unless they had been collected according to standard procedure and their quality assured by exter nal quality assessment. Total Cholesterol
Results on serum total cholesterol showed large interpopulation differences. However, the ranges of median total cholesterol values were practically the same in men (4.1-6.4 mmol/I) as in women (4.2-6.3 mmol/1). Ac cording to the cholesterol limits proposed by the NIH Consensus and the European Ath erosclerosis Society, cholesterol values below 5.2 mmol/1 (200 mg%) are regarded as ideal, intermediate risk is 5.2-6.5 mmol/1, and high risk is above 6.5 mmol/1 (250 mg%), further subdivided in two categories (6.57.8, > 7.8 mmol/1) (300 mg%). There is a wide variety of the proportions of MONICA populations with an ideal cholesterol; these proportions range from 14 up to 87% [7], Within central European MONICA centers, there were however no dramatic differences in cholesterol levels.
Conclusion To summarize the health status of central European countries is a difficult undertak ing. There is a wide variety in morbidity and mortality patterns. Using the examples of cancer of the colon and coronary heart dis ease, wide differences in risk can be demon
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
acute myocardial infarction, medical care in the acute phase and on the major risk fac tors, namely smoking, high blood pressure and serum total cholesterol. The monitoring officially started in 1984 and will finish in 1994. The primary objective of the MONICA project is: ‘To measure the trends and deter minants in cardiovascular mortality and cor onary heart disease and cerebrovascular dis ease morbidity and to assess the extent to which these trends are related to changes in known risk factors, daily living habits, health care or major socio-economic features mea sured at the same time in defined communi ties in different countries’ [6], Thus, the MONICA methodology may serve as an ex ample for monitoring systems of many chronic diseases.
68
Gutzwiller
strated. In part, these differences may relate to differences in life-style, e.g. in dietary hab its and population cholesterol levels. The WHO MONICA study provides a useful methodology to look closer at the relation ship between both mortality and incidence changes with risk factor changes. The results so far obtained in the WHO MONICA pro ject indicate that populations with low levels of risk factors are in the minority. The haz ardous risk factor pattern identified in many populations studied highlights the need to initiate or intensify preventive measures against chronic diseases in these popula tions.
3 Levi F. Maisonneuve P, Filiberti R. et al: Cancer incidence and mortality in Europe. Soz Praventivmcd 1989;vo! 34(suppl 2): 1-84. 4 Pisa Z: Section I. International comparisons: An overview. Int J Epidemiol 1989; 18/3(suppl 1): 19—
20. 5
ERICA Research Group: The CF1D risk-map of Europe (ERICA Project). Eur Heart J 1988: 9(suppl I):I-36. 6 WHO Monica Project principal investigators: The World Health Organization MONICA Project: A major international collaboration. J Clin Epide miol 1988:41/2:105-114. 7 The WHO MONICA Project: Geographical varia tion in the major risk factors of coronary heart disease in men and women aged 35-64 years. World Health Statist Q 1988:41:115-140.
References Prof. Dr. med. et phil. Felix Gutzwiller Institute of Social and Preventive Medicine University of Zürich Sumalrastrasse 30 CH-8006 Zurich (Switzerland)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
1 Willett W: The search for the causes of breast and colon cancer. Nature 1989;338:389-393. 2 Grundy SM, Vega GL: Causes of high blood cho lesterol. Circulation 1990;81:412-427.
Ann Nutr Metab 1991;3S(suppl I ):64—68
Health in Central Europe Felix Gutzwiller Institute of Social and Preventive Medicine, University of Zurich. Switzerland
Key Words. Central Europe • Cancer of colon • Cardiovascular disease • Diet • MONICA study
Introduction The evaluation of health has been an im portant preoccupation of many government agencies and researchers in Europe over the last decade. Health, evaluated convention ally as the absence of ill health, can be expressed as level of risk, morbidity (inci dence and prevalence) and mortality within a given population. Good comparative data on risk are now forthcoming, e.g. within the framework of the international MONICA study, or other epidemiological surveys. In some countries, in the last few years, there has been a development towards national health surveys, including nutritional sur veys, with the aim of monitoring risk and morbidity over time. However, comparative and reliable data on the incidence of major
disease categories are only available in the field of cancer. Mortality statistics are on a reasonably good level in most central Euro pean countries. Still, cross-comparative re search on the validity of comparisons is needed. Of course, it is an impossible under taking to summarize the health patterns of all 11 central European countries. This paper therefore concentrates on two examples of two major disease groups: cancer of the in testines (chiefly colon and rectum), and heart disease (chiefly, coronary heart dis ease, CHD). For both diseases, there is strong evidence of a relationship to dietary fat intake. The overall evidence as summa rized in table 1 is clearly stronger for CHD and dietary fat intake, including experimen tal evidence of changes in disease incidence with changes in dietary fat intake [1, 2],
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
Abstract. Some of the 11 central European countries enjoy today a high level of health, among the highest life expectancies worldwide and. concomitantly, low or intermediate risk factor levels for some of the major chronic diseases. However, on a regional level, and particularly according to social groups, important differences in risk, morbidity and mortal ity still remain. Perhaps the most dramatic differences now found relate to east-west differ ences within Europe. This paper addresses these issues drawing upon examples such as cancer of the colon and coronary heart disease.
Health in Central Europe
30 i
i
65
20 l
t
10 i
10 i
i
l
l
20 i
30 l
l
Fig. I. Average age-standardized (world) mortality rates for cancer of the intestines per 100.000 in Euro pean countries. 1978-1982.
Cancer of the Colon According to a recently published over view. countries with the highest cancer mor tality rates (all sites, males), in 1978-1982, in Europe were Belgium, Czechoslovakia, and Hungary. For females (all sites) the high est rates were in Scotland, Denmark, and Hungary [3]. In general, there is a clear ten dency for southern Europe to have low can cer rates (both for mortality and incidence)
Table 1. Dietary fat. colon cancer and CHD Evidence
Colon cancer
CHD
Animal experiments
+
++
International correlation
++
++
Case control studies
+, h
+
Prospective cohort studies
(+)
++
Experimental
-
+
while central Europe and Scotland were in the upper part of the distribution. Figure 1 presents the age-standardized mortality rates for cancer of the intestines, grouping both colon and rectum cancers for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
After a presentation of the disease pat terns this paper will go on to show how, with an international study protocol, risk factors can be monitored cross-culturally, in order to better understand the variation in the dis ease pattern between countries.
66
Gutzwiller
200
100
100
200
300
400
500
600
Scotland Northern Ireland Finland Czechoslovakia Ireland (84) Hungary England & Wales Norway Denmark Poland Sweden Netherlands FRG Austria Belgium (84) Yugoslavia (83) Italy (83) Switzerland Portugal Spam (81) France
]
Fig. 2. Death rates for heart disease and CHD by sex, ages 45-64, in 27 countries, 1985.
Coronary Heart Disease The highest rates for heart disease within Europe are still in the English speaking and Nordic areas (fig. 2) [4], Within central Eu rope. it is the eastern European countries that have particularly high rates. In addition, even in countries with traditionally low mor tality rates (such as Yugoslavia), these rates are rising. Females have only a fourth or third of the rates of males. Even within cen tral Europe, there are still remarkable differ ences: e.g. even between neighboring coun tries such as France and the FRG.
Reasons for Change: Studies of Mortality Trends For some years now, descriptive risk fac tor data are also available for Europe [5]. A large comparison of European risk factors found for cholesterol that mean values were well above the now accepted ideal of 200 mg/dl. The diminishing values found in the ERICA project from north-west to south east correspond to expectations, although the difference between east and south was nonexistent in men [5], However, still not enough is known about the mechanism by which mortality rates change. To help understand these changes, WHO started a major international collaborative study to monitor the trends and determi nants in cardiovascular disease (MONICA) over a 10-year period within many different populations. The project will provide data on mortality from CHD and incidence of
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
better comparability. Again, some central European countries rank rather high: in fact, Luxembourg tops the mortality statistics. Male and female rates are quite comparable, and there is about a 2-fold difference within central European countries.
67
Health in Central Europe
First Results
In the WHO MONICA project, risk fac tors are monitored through three (two in some populations) independent cross-sec tional population surveys. Although the main objective is to evaluate risk factor trends, the adoption of a standard methodol ogy for the surveys across the MONICA col laborating centers makes it possible to com pare cross-sectional data collected from dif ferent MONICA populations. These results are from the first cross-sectional analysis of levels of the main risk factors in the popula tions studied in the WHO MONICA project at the beginning of the study. In the MONICA study, the smallest pop ulation groups for which data on risk factors are collected are called ‘reporting units’. The sampling strategy was to have representative probability samples within each sex and 10year age group, at least for the age range 3564 years. For the collaborating centers, the
minimal sample size was 200 persons for each sex and 10-year age group. About half of the centers used simple random sampling or systematic random sampling. In the rest of the centers multistage sampling was used. The participation rate achieved varied from 54 to 89%. As a general rule, data were not included in the present analysis unless they had been collected according to standard procedure and their quality assured by exter nal quality assessment. Total Cholesterol
Results on serum total cholesterol showed large interpopulation differences. However, the ranges of median total cholesterol values were practically the same in men (4.1-6.4 mmol/I) as in women (4.2-6.3 mmol/1). Ac cording to the cholesterol limits proposed by the NIH Consensus and the European Ath erosclerosis Society, cholesterol values below 5.2 mmol/1 (200 mg%) are regarded as ideal, intermediate risk is 5.2-6.5 mmol/1, and high risk is above 6.5 mmol/1 (250 mg%), further subdivided in two categories (6.57.8, > 7.8 mmol/1) (300 mg%). There is a wide variety of the proportions of MONICA populations with an ideal cholesterol; these proportions range from 14 up to 87% [7], Within central European MONICA centers, there were however no dramatic differences in cholesterol levels.
Conclusion To summarize the health status of central European countries is a difficult undertak ing. There is a wide variety in morbidity and mortality patterns. Using the examples of cancer of the colon and coronary heart dis ease, wide differences in risk can be demon
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
acute myocardial infarction, medical care in the acute phase and on the major risk fac tors, namely smoking, high blood pressure and serum total cholesterol. The monitoring officially started in 1984 and will finish in 1994. The primary objective of the MONICA project is: ‘To measure the trends and deter minants in cardiovascular mortality and cor onary heart disease and cerebrovascular dis ease morbidity and to assess the extent to which these trends are related to changes in known risk factors, daily living habits, health care or major socio-economic features mea sured at the same time in defined communi ties in different countries’ [6], Thus, the MONICA methodology may serve as an ex ample for monitoring systems of many chronic diseases.
68
Gutzwiller
strated. In part, these differences may relate to differences in life-style, e.g. in dietary hab its and population cholesterol levels. The WHO MONICA study provides a useful methodology to look closer at the relation ship between both mortality and incidence changes with risk factor changes. The results so far obtained in the WHO MONICA pro ject indicate that populations with low levels of risk factors are in the minority. The haz ardous risk factor pattern identified in many populations studied highlights the need to initiate or intensify preventive measures against chronic diseases in these popula tions.
3 Levi F. Maisonneuve P, Filiberti R. et al: Cancer incidence and mortality in Europe. Soz Praventivmcd 1989;vo! 34(suppl 2): 1-84. 4 Pisa Z: Section I. International comparisons: An overview. Int J Epidemiol 1989; 18/3(suppl 1): 19—
20. 5
ERICA Research Group: The CF1D risk-map of Europe (ERICA Project). Eur Heart J 1988: 9(suppl I):I-36. 6 WHO Monica Project principal investigators: The World Health Organization MONICA Project: A major international collaboration. J Clin Epide miol 1988:41/2:105-114. 7 The WHO MONICA Project: Geographical varia tion in the major risk factors of coronary heart disease in men and women aged 35-64 years. World Health Statist Q 1988:41:115-140.
References Prof. Dr. med. et phil. Felix Gutzwiller Institute of Social and Preventive Medicine University of Zürich Sumalrastrasse 30 CH-8006 Zurich (Switzerland)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/24/2018 12:46:27 PM
1 Willett W: The search for the causes of breast and colon cancer. Nature 1989;338:389-393. 2 Grundy SM, Vega GL: Causes of high blood cho lesterol. Circulation 1990;81:412-427.
