© 1991 S. Karger AG. Basel 02 50-6807/91 /0357-0069S2.75/0
Ann Nutr Metab I991;35(suppl 1):69—77
Food Patterns and Health Problems: Health in Southern Europe A. M enolti Laboratory of Epidemiology and Biostatistics, Istituto Superiore di Sanita. Rome, Italy
Key Words. Diet • Health ■Southern Europe • Epidemiology Abstract. The health status description refers to 7 countries of southern Europe, i.e. Por tugal, Spain, France, Italy, Malta, Yugoslavia and Greece, and is mainly derived from offi cial mortality data. In general the health status of southern European countries, as related to the adult population, seems satisfactory and improving along the last 10-15 years in spite of the adverse trends of some diseases. As compared to central, northern and eastern European countries, the southern ones enjoy relatively low mortality and morbidity rates from coro nary heart disease and cardiovascular diseases in general, from lung cancer, from large bowel cancer and all-causes mortality, whereas they suffer from strokes and liver cirrhosis at rela tively high rates. An exception is made by Yugoslavia where trends in death rates from cardiovascular diseases and all-causes mortality are definitely increasing like it has happened in eastern Europe during the last 20 years. Data from official mortality records are supported by information on incidence, mortality and risk factor distribution derived from population studies like the Seven Countries Study, the Erica and the Monica Project.
The identification of southern European countries can be made following different criteria and is exposed to equivocal choices. For the purpose of this presentation the fol lowing countries will be considered in the majority of the occasions: Portugal, Spain, France. Italy. Malta, Yugoslavia and Greece, moving from west to east.
From a strictly geographical point of view, Bulgaria could be added to the list, but it is usually included, for several other rea sons, in the group of the eastern European countries. The inclusion of France is ques tionable, since a large part of its territory and population shares the characteristics of cen tral Europe. This is partly true also for some
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Introduction
70
[1-5], including mortality from several causes, incidence of cardiovascular diseases and risk factors. Something similar, although less homogeneous, can be considered ex ploiting data from the Erica [6] and the Monica projects [7, ].
Official Mortality Data All-Causes Mortality
All-causes mortality, if referred to the adult population, can be considered an im portant indicator to be related to the dietary habits. Data on trends of total mortality for men and women aged 30-60 years in the 7 con sidered countries and referred to two periods (1952-1967 and 1970-1985) are reported in table 1 [9], The years 1968-1969 are ex cluded, because they correspond to the cod ing adjustments made on the occasion of the introduction of the 9th revision of the WHO
Table 1. Percent changes of all-causes mortality rates in people aged 30-69 years in some southern European countries in two time periods of 15 years each Males 52-67 years Portugal Spain France Italy Malta Yugoslavia Greece
-5.7 -17.6 -7 .4 -0 .7 -
-
Females 70-85 years
52-67 years
70-85 years
-23.3 -18.9 -17.1 -17.9 -16.9 + 1.4 -7 .7
-18.0 -31.1 -27.5 -24.1
-31.2 -31.5 -28.2 -29.0 -30.2 -13.1 -19.1
-
-
Computed from Uemura and Pisa [9].
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areas of northern Italy which have also some cultural and socio-economic characteristics of central Europe, while some of the inner parts of Yugoslavia would be better associ ated with eastern Europe. Again it should be recalled that frequently the southern Euro pean countries are associated with the con cept of the Mediterranean world from which, on the other hand, geographically speaking. Portugal should be excluded and other nonEuropean countries should be added. No valuable health information is available from Albania. All this is to say that there are in-built limitations in this analysis of the health problems when such national bound aries are taken as reference. Apart from all such problems the basic characteristic of these countries, at least un til 25-30 years ago and with the exception of France, was of being largely agricultural so cieties whose more or less industrial and pos tindustrial development is relatively recent as compared to the countries of central and northern Europe. The concept of health can be expressed by many different ways, from expectancy of life to quality of life, to all-causes mortality, to specific-causes mortality, to incidence and prevalence of specific diseases, to the levels of risk factors or to the availability of health facilities. However, not all those data are available from the several countries and. if so, not necessarily in a standardized and comparable way. As a consequence most data reported here will be represented by official mortality data in spite of the many biases which they may contain. On the other hand some special input can be obtained from data of specific population samples studied in a standardized way in Ita ly, Yugoslavia and Greece within the Seven Countries Study on cardiovascular diseases
Ménotti
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Health in Southern Europe
international classification of diseases and causes of death [10]. Altogether there is a substantial decline of all-causes mortality. The data do not cover all the countries for the first period, whereas in the second one all of them show a marked decrease ranging from - 13.1 to -31.2% for females and from -7.7 to -23.2% for males, after exclusion of Yugoslavian men who showed a slight in crease of 1.4%.
The net results of these trends are the most recently available data on all-causes mortality in 1985 where in a list of 29 Euro pean countries, such southern European countries are located below the median rate except Yugoslavia and Malta for men and Yugoslavia for women (table 2). The same applies when also the USA, Canada, Japan, Israel. Australia and New Zealand are added to the same list [9],
Country
Males
Country
Females
Hungary Soviet Union Poland Czechoslovakia Romania
1,521 1,374 1.342 1.318 1,154 1,122 1.098 1.060 1.055 1.030 1.008 968 938 938 931 909 907 893 874 857 855 828 769 762 739 710 704 671 614
Hungary Romania Scotland Soviet Union Czechoslovakia Poland
692 620 604 594 576 575 573 536 534 527 522 513 488 487 459 437 432 428 410 387 375 368 357 356 350 345 339 334 333
Yougoslavia
Bulgaria Finland Scotland Northern Ireland GDR Luxemburg Ireland M alta
Austria Belgium Portugal
Denmark Prance
FRG England and Wales Italy
Norway Netherlands Spain
Switzerland Sweden Greece
Iceland
Yugoslavia
Bulgaria Northern Ireland GDR Denmark Ireland England and Wales Luxemburg M alta
Belgium Austria P ortugal
FRG Finland Ita ly
Netherlands Norway Sweden Greece France Spain
Iceland Switzerland
Data are rates per 100,000 for men and women aged 30-69 years. Modified from Uemura and Pisa [9],
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Tabic 2. Age-adjusted mortality rates from all causes in 1985 in 29 European countries
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72
During the two standard time periods be tween 1952 and 1967 and between 1970 and 1985, important changes in the diagnostic possibilities but also in diagnostic habits and fashion occurred. The analysis of this aspect can therefore be protected from important bias by consid ering all cardiovascular diseases together. On the other hand within this large group, which anyhow includes a number of vague and improper diagnoses, at least ischaemic heart disease and stroke have to be consid ered as independent entities. The analysis of trends in mortality is not easy due to the non-homogeneous tendencies. In general, it appears that in the period of 1952-1967 death rates for ischaemic heart disease have been rising, while a recent de cline is evident in France. Italy and Malta and in Portuguese women, whereas in Spain, Yu goslavia and Greece ischaemic heart disease mortality continued its increasing trend [9], Stroke mortality, with the only exception of Yugoslavia, has been declining systemati cally at least between 1970 and 1985 and, even before, at least in France, Spain and Italy [9], The majority of cardiovascular diseases as a whole is usually accounted for by isch aemic heart disease and stroke, and, since there is a uniform tendency toward a mortal ity decline from cardiovascular diseases (ex cept the rise in Yugoslavia), the following conclusions can be drawn from the summary of table 3 which refers to the most recent period of 1970-1985: part of the decline, although proportionally limited, should be ascribed to the well-known disappearance of rheumatic heart disease; the almost univer sal decline of stroke mortality is partly, but not completely, balanced by the rise, at least
Table 3. Changes in death rates from ischaemic heart disease (IHD), cerebrovascular diseases (CVD) and all cardiovascular diseases (ACVD) in men and women aged 30-69 years in some southern European countries in the period of 1970-1985 IHD F
M
F
M
F
-
—
-
-
-
—
•H-
+ -
—
—
0
-
-
—
— —
—
—
—
—
+-H- ++ ++ +
+ 0
0 -
M Portugal Spain France Italy Malta Yugoslavia Greece
ACVD
CVD
0 -
0
++
+
+
-
0= No change or less than ± 10%: += rise 10% or more: ++ = rise 30% or more; +++= rise 50% or more; - = fall 10% or more; — = fall 30% or more: ------- fall 50% or more. Modified from Uemura and Pisa [9],
in some countries, of ischaemic heart dis ease; a large amount of improper diagnoses should be the cause of the large, unexplained and waving differences in total cardiovascu lar deaths. The most recent death rates referring to 1985 [9] and including the 35 countries men tioned above inform us that: for ischaemic heart disease and both males and females the 7 southern European countries are located in the lowest third in the list: the location of the 7 southern European countries in the rank list of the stroke mortality is spread all along the list, with a tendency, for males, to be located above the median; Portugal and Yu goslavia are carrier among the highest rates; for cardiovascular diseases as a whole the rank position of the 7 countries is very low for both males and females, except Malta and Yugoslavia.
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Mortality from Cardiovascular Diseases
73
Health in Southern Europe
Table 4. Rank positions of 7 southern European countries according to death rates from selected causes of death All causes
Cardiovascular
All cancers
Breast cancer
Liver cirrhosis
(age 30-60 years)
(age 30-69 years)
(age 0-99 years)
(age 30-64 years)
(age 30-69 years)
M
F
M
F
M
F
F
M
Portugal Spain France Italy Malta Yugoslavia Greece
16 28 19 23 13 5 32
21 32 31 26 18 7 30
29 32 34 30 12 11 31
19 28 35 26 12 5 25
24 19 6 10
21 25 17 16
-
-
22 20
22 23
20 24 16 14 11 26 23
2 8 6 4 12 7 20
Countries in the list, n
35
35
35
35
26
26
27
27
1975-1979
1980-1984
11
11
Years Reference No.
1985
1985
1984
9
9
13
Part of table 4 covers this kind of infor mation. The picture is therefore composite and non-homogeneous although tendentially di rected toward relatively favourable trends. Cancer The analysis of cancer is complicated by the fact that there are many different ana tomical locations, each of them having dif ferent risk factors. For practical purposes the most common cancer in Europe, i.e. lung cancer, has to be excluded from the analysis, since the possible links with eating habits are at least uncertain. Other sites, like breast, oesophagus, stomach and large bowels de serve specific attention. In the late seventies, breast cancer mor tality in females aged 30-64 years in 27 European countries showed a twofold differ
ence between the extremes (England and Wales with a rate of over 50 per 100,000 per year and Romania with a rate of about 25). The countries of southern Europe were lo cated below the median except Malta [11]. Still, during the previous 20 years, Spain, Greece and Malta suffered among others the greatest increase in death rates [11], The incidence of cancer of the oesopha gus, in men aged 35-64 years in studies made between 1966 and 1976, showed rela tively high levels in southern Europe as com pared to eastern and northern Europe but lower levels than in some areas of western Europe and of the USSR [II], Cancer of the stomach is a condition which is declining in most countries, and this has been the case during the last 20 years also in the southern European ones. Their rank positions in 1981-1984, in terms of
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Results are reconstructed from those in the given references.
Ménotti
74
Liver Cirrhosis This is a condition which is prevailing in southern Europe as compared to the other areas. In a list of 26 countries, mortality data for men aged 55-59 years in 1980-1984 indicate that the 7 southern European coun tries rank in positions, 2, 4, 6, 7, 8, 10 and 20 suggesting the existence of a real problem [9] (table 4). In Italy a recent analysis showed that about 40% of liver cirrhosis fatalities in men and 25% in women are attributable to alcohol consumption [14], In general, the health conditions, as judged by the mortality rates in the adult population and with the exception of the Yugoslavian males, should have improved along the last three decades. This is the indi cation coming from the trends and levels of total mortality in adults as reported in ta bles 1 and 4. Moreover this suggests that the trends of single causes of death in the same period of time may be the consequence of
many factors, including coding artifacts. As a consequence the study of the correlation of such trends with dietary factors alone might be misleading and call for multivariate ap proaches. In addition problems concerning competing risks among different risk factors, including the dietary ones, have to be con sidered.
Special Population Studies The longitudinal study known as the Seven Countries Study on cardiovascular diseases can be exploited for comparison be tween 3 southern European countries (Italy with 3 samples, Yugoslavia with 5 and Greece with 2) and 2 northern European ones (the Netherlands with 1 sample and Finland with 2) [1-4], All the studied co horts were made of men aged 40-59 years at entry and followed-up for 25 years for mor tality and for shorter periods for coronary incidence, after repeated measurements of several risk factors and dietary habits [1-5]. They do not represent necessarily their coun tries and the geographical regions where they are located, but the available results are in line with the official mortality data. However, the meaning of these data is peculiar, since they refer to ageing cohorts and therefore the age and period compo nents have to be taken into account for a proper interpretation. On the other hand the incidence and mortality data measured in these cohorts have the advantage of high accuracy, homogeneous diagnostic criteria and analysis. Already in an early report, covering a 5year follow-up [ 1], it was shown that the inci dence of coronary heart disease was higher in Finland (198 per 1.000) and in the Neth-
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mortality rates among 27 European coun tries (males), are spread along the whole range [11]. Part of this information is re ported in table 4. Cancer of the large bowels is a condition difficult to analyse, since recently the coding of this disease has changed. In general the distinction between colon and rectal cancer is difficult and little accurate. However, some data show a positive correlation be tween meat consumption and fat consump tion on one side and colon cancer mortality on the other, with some of the Mediterra nean countries located in the lower part of the rank list [12]. In general also when pooling together the all-cancers mortality in the European coun tries [ 13], lower rates are found in southern Europe as compared to other areas.
75
Health in Southern Europe
Table5. Seven Countries Study: 15-year death rates per 1,000 in northern and southern European cohorts Northern Southern S/N, % All causes 261 Coronary heart disease 111 17 Stroke Lung cancer 28 44 Other cancers All cancers 72
196 36 26 10 40 50
75 32 152 38 91 69
Computed from Keys et al. [3, 5],
tant. Median age-specific levels at the time of the entry examination around 1960 were between 226 and 272 mg/dl in the Nether lands and in Finland and all below 212 in the southern European cohorts of Italy, Yugosla via and Greece [ 1]. On the other hand during the first 10 years of follow-up, the greatest increase in such median levels occurred in some of the Yugoslavian cohorts which are from the same areas exhibiting the greatest increase in coronary and all-causes mortality in the most recent years [2, 15]. The Erica study has represented a great effort in collecting, collating and homogeniz ing a large number of studies on population samples conducted in the seventies with a basic interest for coronary heart disease [6], In its first report, the available data on some major coronary risk factors were presented by dividing Europe in 4 areas, i.e. north, west, east and south. Nine samples in 4 countries (Portugal. Spain, Italy and Greece) represented southern Europe, while France was included in western Europe. Once more it was shown that mean serum cholesterol levels were lower in the south as compared to the western and northern European cohorts.
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erlands (139 per 1,000) and definitely lower in Italy (100 per 1,000), Yugoslavia (53 per 1,000) and Greece (32 per 1,000). Table 5 reports the 15-year age-standard ized death rates from some causes in the pools of the northern and southern European cohorts. The advantage of the southern pop ulations is clear-cut for coronary heart dis ease, for lung cancer, not so much for the other cancer locations, whereas death rates from stroke are higher in southern than in northern cohorts. Still the overall balance is favourable to the southern countries having a lower all-causes mortality of about 25% and consequently a longer expectancy of life than the northern counterpart. This kind of data and those from shorter and longer follow-up periods have been found to be correlated with the consumption of some nutrients [1, 2, 4, 15]. In particular the consumption of saturated fat was always found positively and highly statistically cor related with coronary mortality (r= 0.80 or more) [1, 2. 4, 15], whereas the M/S ratio (ratio between mono-unsaturated fats and saturated fats) was inversely related to coro nary heart disease, to cancer mortality and to all causes of death [4], The mentioned relationships refer to a block of 15 years of follow-up. However, in a recent report [ 15] and in unpublished analy ses it appears that the quinquennial noncumulative death rates, at least from some causes, have been increasing more sharply in Yugoslavia than in other countries, and after 25 years in the cohorts of this country all causes mortality becomes the highest in Eu rope after that of the Finnish samples [unpubl. pers. data]. Among the risk factors measured in this study and known as linked to the habitual diet, serum cholesterol is the most impor-
76
Menotti
whereas similar values were found in eastern European men and higher values in eastern European women (table 6). Serum choles terol levels greatly contributed to the esti mated coronary risk in this study which, for
Table 6. Erica Project [6]: mean levels of serum cholesterol of men and women aged 40-59 years belonging to the cohorts studied in 4 European re gions Region
North West East South
Countries Cohorts Cholesterol, mg/dl
5 5 3 4
5 6 6 9
M
F
243.2 231.1 220.2 222.4
253.8 235.7 253.1 225.5
Note: in this study France is included in western Europe. Modified data.
men aged 40-59 years, was lower in the south than in the west and the north. The Monica project represents the wellknown surveillance system of some cardio vascular diseases launched by the WHO in the early eighties, involving about 40 differ ent areas in 26 countries [7, 8], The first report is concerned with mortality data of a single year, and it confirms the geographical distribution shown by the official national mortality data. Table 7 describes the posi tions of 9 southern European areas (in Spain, France. Italy, Yugoslavia, Malta) over a total of 32 areas, spread in Europe, in northern America, in China and in Australasia. It con firms the favourable position of the southern European areas for all-causes mortality, for cardiovascular diseases and ischaemic heart disease, whereas for stroke mortality the sites are spread over the whole range. It should be recalled that this occurs, although two areas from northern France and two
Table 7. Monica Project [7]: rank position of 9 southern European areas in a list of 32 areas ACVD
IHD
STR
M
F
M
F
M
F
M
F
2 (N) 6(L) 7(B) 12 (S) 16(F) 23 (LT) 25 (T) 20 (C) 31 (M)
3(B) 4 (N) 8 (L) 20(F) 23 (S) 27 (LT) 29 (M) 31 (T) 32(C)
2 (N) 8(B) 2 3 (LT) 24 (S) 26 (L) 27(F) 29 (M) 31 (T) 32 (C)
3(B) 4 (N) 20 (M) 21 (LT) 24 (F) 26 (L) 28 (S) 31 (C) 32 (T)
5(N) 21 (B) 25 (S) 26 (M) 27 (LT) 28 (L) 29 (T) 30 (C) 31 (F)
5(N) 8
Ann Nutr Metab I991;35(suppl 1):69—77
Food Patterns and Health Problems: Health in Southern Europe A. M enolti Laboratory of Epidemiology and Biostatistics, Istituto Superiore di Sanita. Rome, Italy
Key Words. Diet • Health ■Southern Europe • Epidemiology Abstract. The health status description refers to 7 countries of southern Europe, i.e. Por tugal, Spain, France, Italy, Malta, Yugoslavia and Greece, and is mainly derived from offi cial mortality data. In general the health status of southern European countries, as related to the adult population, seems satisfactory and improving along the last 10-15 years in spite of the adverse trends of some diseases. As compared to central, northern and eastern European countries, the southern ones enjoy relatively low mortality and morbidity rates from coro nary heart disease and cardiovascular diseases in general, from lung cancer, from large bowel cancer and all-causes mortality, whereas they suffer from strokes and liver cirrhosis at rela tively high rates. An exception is made by Yugoslavia where trends in death rates from cardiovascular diseases and all-causes mortality are definitely increasing like it has happened in eastern Europe during the last 20 years. Data from official mortality records are supported by information on incidence, mortality and risk factor distribution derived from population studies like the Seven Countries Study, the Erica and the Monica Project.
The identification of southern European countries can be made following different criteria and is exposed to equivocal choices. For the purpose of this presentation the fol lowing countries will be considered in the majority of the occasions: Portugal, Spain, France. Italy. Malta, Yugoslavia and Greece, moving from west to east.
From a strictly geographical point of view, Bulgaria could be added to the list, but it is usually included, for several other rea sons, in the group of the eastern European countries. The inclusion of France is ques tionable, since a large part of its territory and population shares the characteristics of cen tral Europe. This is partly true also for some
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Introduction
70
[1-5], including mortality from several causes, incidence of cardiovascular diseases and risk factors. Something similar, although less homogeneous, can be considered ex ploiting data from the Erica [6] and the Monica projects [7, ].
Official Mortality Data All-Causes Mortality
All-causes mortality, if referred to the adult population, can be considered an im portant indicator to be related to the dietary habits. Data on trends of total mortality for men and women aged 30-60 years in the 7 con sidered countries and referred to two periods (1952-1967 and 1970-1985) are reported in table 1 [9], The years 1968-1969 are ex cluded, because they correspond to the cod ing adjustments made on the occasion of the introduction of the 9th revision of the WHO
Table 1. Percent changes of all-causes mortality rates in people aged 30-69 years in some southern European countries in two time periods of 15 years each Males 52-67 years Portugal Spain France Italy Malta Yugoslavia Greece
-5.7 -17.6 -7 .4 -0 .7 -
-
Females 70-85 years
52-67 years
70-85 years
-23.3 -18.9 -17.1 -17.9 -16.9 + 1.4 -7 .7
-18.0 -31.1 -27.5 -24.1
-31.2 -31.5 -28.2 -29.0 -30.2 -13.1 -19.1
-
-
Computed from Uemura and Pisa [9].
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areas of northern Italy which have also some cultural and socio-economic characteristics of central Europe, while some of the inner parts of Yugoslavia would be better associ ated with eastern Europe. Again it should be recalled that frequently the southern Euro pean countries are associated with the con cept of the Mediterranean world from which, on the other hand, geographically speaking. Portugal should be excluded and other nonEuropean countries should be added. No valuable health information is available from Albania. All this is to say that there are in-built limitations in this analysis of the health problems when such national bound aries are taken as reference. Apart from all such problems the basic characteristic of these countries, at least un til 25-30 years ago and with the exception of France, was of being largely agricultural so cieties whose more or less industrial and pos tindustrial development is relatively recent as compared to the countries of central and northern Europe. The concept of health can be expressed by many different ways, from expectancy of life to quality of life, to all-causes mortality, to specific-causes mortality, to incidence and prevalence of specific diseases, to the levels of risk factors or to the availability of health facilities. However, not all those data are available from the several countries and. if so, not necessarily in a standardized and comparable way. As a consequence most data reported here will be represented by official mortality data in spite of the many biases which they may contain. On the other hand some special input can be obtained from data of specific population samples studied in a standardized way in Ita ly, Yugoslavia and Greece within the Seven Countries Study on cardiovascular diseases
Ménotti
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Health in Southern Europe
international classification of diseases and causes of death [10]. Altogether there is a substantial decline of all-causes mortality. The data do not cover all the countries for the first period, whereas in the second one all of them show a marked decrease ranging from - 13.1 to -31.2% for females and from -7.7 to -23.2% for males, after exclusion of Yugoslavian men who showed a slight in crease of 1.4%.
The net results of these trends are the most recently available data on all-causes mortality in 1985 where in a list of 29 Euro pean countries, such southern European countries are located below the median rate except Yugoslavia and Malta for men and Yugoslavia for women (table 2). The same applies when also the USA, Canada, Japan, Israel. Australia and New Zealand are added to the same list [9],
Country
Males
Country
Females
Hungary Soviet Union Poland Czechoslovakia Romania
1,521 1,374 1.342 1.318 1,154 1,122 1.098 1.060 1.055 1.030 1.008 968 938 938 931 909 907 893 874 857 855 828 769 762 739 710 704 671 614
Hungary Romania Scotland Soviet Union Czechoslovakia Poland
692 620 604 594 576 575 573 536 534 527 522 513 488 487 459 437 432 428 410 387 375 368 357 356 350 345 339 334 333
Yougoslavia
Bulgaria Finland Scotland Northern Ireland GDR Luxemburg Ireland M alta
Austria Belgium Portugal
Denmark Prance
FRG England and Wales Italy
Norway Netherlands Spain
Switzerland Sweden Greece
Iceland
Yugoslavia
Bulgaria Northern Ireland GDR Denmark Ireland England and Wales Luxemburg M alta
Belgium Austria P ortugal
FRG Finland Ita ly
Netherlands Norway Sweden Greece France Spain
Iceland Switzerland
Data are rates per 100,000 for men and women aged 30-69 years. Modified from Uemura and Pisa [9],
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Tabic 2. Age-adjusted mortality rates from all causes in 1985 in 29 European countries
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During the two standard time periods be tween 1952 and 1967 and between 1970 and 1985, important changes in the diagnostic possibilities but also in diagnostic habits and fashion occurred. The analysis of this aspect can therefore be protected from important bias by consid ering all cardiovascular diseases together. On the other hand within this large group, which anyhow includes a number of vague and improper diagnoses, at least ischaemic heart disease and stroke have to be consid ered as independent entities. The analysis of trends in mortality is not easy due to the non-homogeneous tendencies. In general, it appears that in the period of 1952-1967 death rates for ischaemic heart disease have been rising, while a recent de cline is evident in France. Italy and Malta and in Portuguese women, whereas in Spain, Yu goslavia and Greece ischaemic heart disease mortality continued its increasing trend [9], Stroke mortality, with the only exception of Yugoslavia, has been declining systemati cally at least between 1970 and 1985 and, even before, at least in France, Spain and Italy [9], The majority of cardiovascular diseases as a whole is usually accounted for by isch aemic heart disease and stroke, and, since there is a uniform tendency toward a mortal ity decline from cardiovascular diseases (ex cept the rise in Yugoslavia), the following conclusions can be drawn from the summary of table 3 which refers to the most recent period of 1970-1985: part of the decline, although proportionally limited, should be ascribed to the well-known disappearance of rheumatic heart disease; the almost univer sal decline of stroke mortality is partly, but not completely, balanced by the rise, at least
Table 3. Changes in death rates from ischaemic heart disease (IHD), cerebrovascular diseases (CVD) and all cardiovascular diseases (ACVD) in men and women aged 30-69 years in some southern European countries in the period of 1970-1985 IHD F
M
F
M
F
-
—
-
-
-
—
•H-
+ -
—
—
0
-
-
—
— —
—
—
—
—
+-H- ++ ++ +
+ 0
0 -
M Portugal Spain France Italy Malta Yugoslavia Greece
ACVD
CVD
0 -
0
++
+
+
-
0= No change or less than ± 10%: += rise 10% or more: ++ = rise 30% or more; +++= rise 50% or more; - = fall 10% or more; — = fall 30% or more: ------- fall 50% or more. Modified from Uemura and Pisa [9],
in some countries, of ischaemic heart dis ease; a large amount of improper diagnoses should be the cause of the large, unexplained and waving differences in total cardiovascu lar deaths. The most recent death rates referring to 1985 [9] and including the 35 countries men tioned above inform us that: for ischaemic heart disease and both males and females the 7 southern European countries are located in the lowest third in the list: the location of the 7 southern European countries in the rank list of the stroke mortality is spread all along the list, with a tendency, for males, to be located above the median; Portugal and Yu goslavia are carrier among the highest rates; for cardiovascular diseases as a whole the rank position of the 7 countries is very low for both males and females, except Malta and Yugoslavia.
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Mortality from Cardiovascular Diseases
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Health in Southern Europe
Table 4. Rank positions of 7 southern European countries according to death rates from selected causes of death All causes
Cardiovascular
All cancers
Breast cancer
Liver cirrhosis
(age 30-60 years)
(age 30-69 years)
(age 0-99 years)
(age 30-64 years)
(age 30-69 years)
M
F
M
F
M
F
F
M
Portugal Spain France Italy Malta Yugoslavia Greece
16 28 19 23 13 5 32
21 32 31 26 18 7 30
29 32 34 30 12 11 31
19 28 35 26 12 5 25
24 19 6 10
21 25 17 16
-
-
22 20
22 23
20 24 16 14 11 26 23
2 8 6 4 12 7 20
Countries in the list, n
35
35
35
35
26
26
27
27
1975-1979
1980-1984
11
11
Years Reference No.
1985
1985
1984
9
9
13
Part of table 4 covers this kind of infor mation. The picture is therefore composite and non-homogeneous although tendentially di rected toward relatively favourable trends. Cancer The analysis of cancer is complicated by the fact that there are many different ana tomical locations, each of them having dif ferent risk factors. For practical purposes the most common cancer in Europe, i.e. lung cancer, has to be excluded from the analysis, since the possible links with eating habits are at least uncertain. Other sites, like breast, oesophagus, stomach and large bowels de serve specific attention. In the late seventies, breast cancer mor tality in females aged 30-64 years in 27 European countries showed a twofold differ
ence between the extremes (England and Wales with a rate of over 50 per 100,000 per year and Romania with a rate of about 25). The countries of southern Europe were lo cated below the median except Malta [11]. Still, during the previous 20 years, Spain, Greece and Malta suffered among others the greatest increase in death rates [11], The incidence of cancer of the oesopha gus, in men aged 35-64 years in studies made between 1966 and 1976, showed rela tively high levels in southern Europe as com pared to eastern and northern Europe but lower levels than in some areas of western Europe and of the USSR [II], Cancer of the stomach is a condition which is declining in most countries, and this has been the case during the last 20 years also in the southern European ones. Their rank positions in 1981-1984, in terms of
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Results are reconstructed from those in the given references.
Ménotti
74
Liver Cirrhosis This is a condition which is prevailing in southern Europe as compared to the other areas. In a list of 26 countries, mortality data for men aged 55-59 years in 1980-1984 indicate that the 7 southern European coun tries rank in positions, 2, 4, 6, 7, 8, 10 and 20 suggesting the existence of a real problem [9] (table 4). In Italy a recent analysis showed that about 40% of liver cirrhosis fatalities in men and 25% in women are attributable to alcohol consumption [14], In general, the health conditions, as judged by the mortality rates in the adult population and with the exception of the Yugoslavian males, should have improved along the last three decades. This is the indi cation coming from the trends and levels of total mortality in adults as reported in ta bles 1 and 4. Moreover this suggests that the trends of single causes of death in the same period of time may be the consequence of
many factors, including coding artifacts. As a consequence the study of the correlation of such trends with dietary factors alone might be misleading and call for multivariate ap proaches. In addition problems concerning competing risks among different risk factors, including the dietary ones, have to be con sidered.
Special Population Studies The longitudinal study known as the Seven Countries Study on cardiovascular diseases can be exploited for comparison be tween 3 southern European countries (Italy with 3 samples, Yugoslavia with 5 and Greece with 2) and 2 northern European ones (the Netherlands with 1 sample and Finland with 2) [1-4], All the studied co horts were made of men aged 40-59 years at entry and followed-up for 25 years for mor tality and for shorter periods for coronary incidence, after repeated measurements of several risk factors and dietary habits [1-5]. They do not represent necessarily their coun tries and the geographical regions where they are located, but the available results are in line with the official mortality data. However, the meaning of these data is peculiar, since they refer to ageing cohorts and therefore the age and period compo nents have to be taken into account for a proper interpretation. On the other hand the incidence and mortality data measured in these cohorts have the advantage of high accuracy, homogeneous diagnostic criteria and analysis. Already in an early report, covering a 5year follow-up [ 1], it was shown that the inci dence of coronary heart disease was higher in Finland (198 per 1.000) and in the Neth-
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mortality rates among 27 European coun tries (males), are spread along the whole range [11]. Part of this information is re ported in table 4. Cancer of the large bowels is a condition difficult to analyse, since recently the coding of this disease has changed. In general the distinction between colon and rectal cancer is difficult and little accurate. However, some data show a positive correlation be tween meat consumption and fat consump tion on one side and colon cancer mortality on the other, with some of the Mediterra nean countries located in the lower part of the rank list [12]. In general also when pooling together the all-cancers mortality in the European coun tries [ 13], lower rates are found in southern Europe as compared to other areas.
75
Health in Southern Europe
Table5. Seven Countries Study: 15-year death rates per 1,000 in northern and southern European cohorts Northern Southern S/N, % All causes 261 Coronary heart disease 111 17 Stroke Lung cancer 28 44 Other cancers All cancers 72
196 36 26 10 40 50
75 32 152 38 91 69
Computed from Keys et al. [3, 5],
tant. Median age-specific levels at the time of the entry examination around 1960 were between 226 and 272 mg/dl in the Nether lands and in Finland and all below 212 in the southern European cohorts of Italy, Yugosla via and Greece [ 1]. On the other hand during the first 10 years of follow-up, the greatest increase in such median levels occurred in some of the Yugoslavian cohorts which are from the same areas exhibiting the greatest increase in coronary and all-causes mortality in the most recent years [2, 15]. The Erica study has represented a great effort in collecting, collating and homogeniz ing a large number of studies on population samples conducted in the seventies with a basic interest for coronary heart disease [6], In its first report, the available data on some major coronary risk factors were presented by dividing Europe in 4 areas, i.e. north, west, east and south. Nine samples in 4 countries (Portugal. Spain, Italy and Greece) represented southern Europe, while France was included in western Europe. Once more it was shown that mean serum cholesterol levels were lower in the south as compared to the western and northern European cohorts.
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erlands (139 per 1,000) and definitely lower in Italy (100 per 1,000), Yugoslavia (53 per 1,000) and Greece (32 per 1,000). Table 5 reports the 15-year age-standard ized death rates from some causes in the pools of the northern and southern European cohorts. The advantage of the southern pop ulations is clear-cut for coronary heart dis ease, for lung cancer, not so much for the other cancer locations, whereas death rates from stroke are higher in southern than in northern cohorts. Still the overall balance is favourable to the southern countries having a lower all-causes mortality of about 25% and consequently a longer expectancy of life than the northern counterpart. This kind of data and those from shorter and longer follow-up periods have been found to be correlated with the consumption of some nutrients [1, 2, 4, 15]. In particular the consumption of saturated fat was always found positively and highly statistically cor related with coronary mortality (r= 0.80 or more) [1, 2. 4, 15], whereas the M/S ratio (ratio between mono-unsaturated fats and saturated fats) was inversely related to coro nary heart disease, to cancer mortality and to all causes of death [4], The mentioned relationships refer to a block of 15 years of follow-up. However, in a recent report [ 15] and in unpublished analy ses it appears that the quinquennial noncumulative death rates, at least from some causes, have been increasing more sharply in Yugoslavia than in other countries, and after 25 years in the cohorts of this country all causes mortality becomes the highest in Eu rope after that of the Finnish samples [unpubl. pers. data]. Among the risk factors measured in this study and known as linked to the habitual diet, serum cholesterol is the most impor-
76
Menotti
whereas similar values were found in eastern European men and higher values in eastern European women (table 6). Serum choles terol levels greatly contributed to the esti mated coronary risk in this study which, for
Table 6. Erica Project [6]: mean levels of serum cholesterol of men and women aged 40-59 years belonging to the cohorts studied in 4 European re gions Region
North West East South
Countries Cohorts Cholesterol, mg/dl
5 5 3 4
5 6 6 9
M
F
243.2 231.1 220.2 222.4
253.8 235.7 253.1 225.5
Note: in this study France is included in western Europe. Modified data.
men aged 40-59 years, was lower in the south than in the west and the north. The Monica project represents the wellknown surveillance system of some cardio vascular diseases launched by the WHO in the early eighties, involving about 40 differ ent areas in 26 countries [7, 8], The first report is concerned with mortality data of a single year, and it confirms the geographical distribution shown by the official national mortality data. Table 7 describes the posi tions of 9 southern European areas (in Spain, France. Italy, Yugoslavia, Malta) over a total of 32 areas, spread in Europe, in northern America, in China and in Australasia. It con firms the favourable position of the southern European areas for all-causes mortality, for cardiovascular diseases and ischaemic heart disease, whereas for stroke mortality the sites are spread over the whole range. It should be recalled that this occurs, although two areas from northern France and two
Table 7. Monica Project [7]: rank position of 9 southern European areas in a list of 32 areas ACVD
IHD
STR
M
F
M
F
M
F
M
F
2 (N) 6(L) 7(B) 12 (S) 16(F) 23 (LT) 25 (T) 20 (C) 31 (M)
3(B) 4 (N) 8 (L) 20(F) 23 (S) 27 (LT) 29 (M) 31 (T) 32(C)
2 (N) 8(B) 2 3 (LT) 24 (S) 26 (L) 27(F) 29 (M) 31 (T) 32 (C)
3(B) 4 (N) 20 (M) 21 (LT) 24 (F) 26 (L) 28 (S) 31 (C) 32 (T)
5(N) 21 (B) 25 (S) 26 (M) 27 (LT) 28 (L) 29 (T) 30 (C) 31 (F)
5(N) 8
