(Stroke. 1995;26:2222-2227.)
© 1995 American Heart Association, Inc.
Articles |
Stroke in the People's Republic of China
I. Geographic Variations in Incidence and Risk Factors
From the Welch Center for Prevention, Epidemiology, and Clinical Research (J.H., M.J.K., P.K.W.), the Department of Epidemiology (J.H., M.J.K., P.K.W.), the Department of Medicine (M.J.K., P.K.W.), and the Department of Health Policy and Management (M.J.K.), The Johns Hopkins University School of Hygiene and Public Health and School of Medicine, Baltimore, Md, and the Department of Epidemiology, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China (Z.W.).
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Abstract |
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Background and Purpose Stroke is a major cause of death in the People's Republic of China (PRC), and the geographic distribution of stroke death varies substantially. We conducted an ecological analysis to investigate the relationship of prevalence of hypertension and other risk factors with stroke incidence and mortality in the PRC.
Methods The relationship between prevalence of risk factors and stroke incidence and mortality in the PRC was assessed in 29 provinces by examining risk factor data from PRC national surveys and incidence and mortality from the 1986 PRC National Stroke Study.
Results A highly statistically significant correlation between prevalence of hypertension and stroke incidence (r=.838, P<.001) and mortality (r=.841, P<.001) was observed. Prevalence of hypertension explained over 70% of the geographic variability in stroke incidence (partial R2=.703) and mortality (partial R2=.707) in the PRC. There was a north-south gradient, with a higher prevalence of hypertension and stroke incidence and mortality in the north compared with the south of the country. In multiple Poisson regression analysis, a 10% increase in the prevalence of hypertension was associated with a 2.80-fold higher incidence and 2.68-fold higher mortality from stroke, whereas a 10% increase in the prevalence of alcohol consumption was associated with a 29% higher incidence and a 16% higher mortality from stroke. A 10% increase in the prevalence of cigarette smoking was associated with a 19% higher mortality from stroke.
Conclusions In the PRC, the prevalence of hypertension is strongly associated with the risk of stroke, and the geographic variation in stroke incidence and mortality is due mainly to differences in the prevalence of hypertension.
Key Words: China • epidemiology • hypertension • incidence • stroke
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Stroke is the second most common cause of death among urban residents and the third most common cause of death in rural residents of the People's Republic of China (PRC).1 Each year, more than 1 million residents of the PRC die from stroke, three times as many as die from ischemic heart disease.1
The geographic distribution of stroke incidence and mortality in the PRC varies by region. This regional variation has been documented in the PRC Six-City Stroke Study,2 the Sino-MONICA Study,3 and the PRC National Stroke Study,4 all of which noted a north-south gradient with a significantly higher incidence and mortality of stroke in the north compared with the south.2 3 4 However, the reasons for this geographic variation have not been well studied.
The purpose of the present study was to investigate the relationship between the prevalence of stroke risk factors, especially hypertension, and stroke incidence and mortality.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Data from the 1986 PRC National Stroke Study and the 1979-1980 PRC National Hypertension Survey were used to conduct a series of ecological analyses. Details of the design and methods for both studies have been described elsewhere.4 5
1986 PRC National Stroke Study
The 1986 National Stroke Survey was designed to investigate the
distribution of stroke in the PRC.4 The survey sample
consisted of a representative group of 5 790 864
residents of the PRC drawn from 199 cluster samples, each of which
included about 25 000 to 30 000 community dwellers. A multistage,
random cluster sampling method was used for selection of study
participants in urban areas. In each city, several districts were
randomly selected, and several neighborhoods were randomly selected
from each district. All residents living in these neighborhoods were
invited to participate in the study. The response rate for the study
was >95%. For rural areas, a representative sample
was selected from each prefecture according to the distribution of age
and sex of the population, socioeconomic characteristics, and
geographic and climatic conditions. The sampling frame was 0.5% of the
general population of the PRC. Within each province, the urban and
rural samples were pooled to provide average estimates of fatal and
nonfatal stroke rates.
Incident cases and deaths from stroke between January 1 and December 31, 1986, were identified by means of a house-to-house survey of the study sample. Incident cases included those who experienced either a fatal or nonfatal first completed stroke during 1986. Subjects who presented before January 1, 1986, and were still alive in 1986 were excluded. Death certificates from all persons who were reported to have died during 1986 were reviewed to identify those who died from a stroke. Nonfatal cases of stroke were diagnosed by specially trained neurologists who reviewed the participant's responses to standardized questions designed to elicit a history of stroke symptoms or treatment and who reviewed records from hospitalizations that might have included treatment for stroke.6
1979-1980 PRC National Hypertension Survey
The National Hypertension Survey was conducted during August,
September, and October of 1979 and 1980.5 The survey
sample included a total of 4 012 128 residents of the PRC who were
15 years of age. They were selected from 90 cities (urban residents)
and 208 prefectures (rural residents). Several cluster samples, each
consisting of 1 000 to 2 000 participants, were drawn from each city
or prefecture. About 12 000 residents from each city or prefecture
participated in the survey. Special attention was paid to ensure that
the samples represented the general population in
distribution of age, sex, and occupation. Three blood pressure
measurements were obtained at a single visit according to standard
World Health Organization (WHO) procedures.5 For this
analysis, hypertension was defined as the presence of an
average systolic blood pressure 140 mm Hg, an average
diastolic blood pressure 90 mm Hg, or reported treatment
with an antihypertensive medication. The prevalences of hypertension in
the urban and rural areas within each province were pooled to provide
an overall estimate of the prevalence of hypertension for each
province.
Other Data Sources
The prevalence of cigarette smoking by province was obtained
from the 1984 PRC National Smoking Prevalence Survey.7 A
total of 519 600 persons aged 15 years or older, a stratified random
sample from the general population, participated in this survey. The
prevalence of alcohol consumption for each province was abstracted from
the PRC 1991 National Survey, which was conducted in a random sample of
the general population consisting of 924 048 persons, aged 17 to 74
years.8 The population density and the proportion of the
population living in urban areas were obtained from the 1990 PRC
population census.9
Statistical Methods
Age-specific incidence and mortality rates of stroke for the
29 provinces were abstracted from the results of the 1986 PRC National
Stroke Study.10 Age-standardized rates were calculated
by the direct method using the 1960 United States total population as
the standard population. The numbers of age-standardized stroke
cases per province were calculated using age-standardized rates and
population sizes from the 1986 PRC National Stroke Study.
Age-standardized prevalences by province of hypertension, cigarette
smoking, and alcohol consumption were also obtained.7 8 11
Correlation analysis was used to explore the association of
prevalence of hypertension, cigarette smoking, and alcohol consumption
with stroke incidence and mortality, by province. The partial
coefficients of determination (R2) were
calculated with multiple linear regression analysis.
Univariate and multiple Poisson regression were used to
estimate the relative risks of stroke associated with the prevalence of
these risk factors. The numbers of age-standardized incident and
fatal stroke cases for each province were used as outcomes in the
Poisson regressions. Population density and proportion of urban
dwellers were included in multivariate models because
they were associated with both risk factors and stroke rates. Other
risk factors examined (hypertension, cigarette smoking, and alcohol
consumption) were also included as covariates. However, hypertension
was not included in the model to assess the relative risk for alcohol
consumption because hypertension is likely to be a part of the causal
chain between alcohol consumption and stroke.12
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The overall annual age-standardized incidence and death rates from stroke in the general population of the PRC were 115.61 and 81.88 per 100 000, respectively, in 1986 (Table 1
). There were remarkable geographic
differences in the distribution of stroke incidence and mortality. The
age-standardized incidence of stroke varied almost 8.5-fold, from
53.2 per 100 000 in Guangdong (Canton) to 450.4 per 100 000 persons
in Tibet. The age-standardized stroke mortality varied 8.3-fold,
from 44.7 per 100 000 in Inner Mongolia to 370.2 per 100 000 persons
in Tibet. There was an impressive north-south gradient in stroke
incidence and mortality: the rates for both were higher in the densely
populated northeastern areas of the PRC compared with those in the
south. For example, in each of the northeastern provinces, the
age-standardized incidence of stroke was in the upper quartile for
all provinces (per 100 000 persons: 202.75 in Heilongjiang, 234.4 in
Jilin, and 191.35 in Liaoning province), whereas the
age-standardized incidence of stroke was in the lowest quartile in
most of the southern provinces (Fig 1).
Although the overall pattern of stroke incidence identified higher
rates in the northern provinces compared with those in the south, there
were exceptions. Tibet had the highest incidence and mortality of
stroke among all of the 29 provinces studied, and in the southern
province of Hunan and in Shanghai City, the incidence of
stroke was 141.15 and 144.85 per 100 000 persons, respectively.
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The overall prevalence of hypertension in the general population of the
PRC was 7.7% in 1979 through 1980 (Table 1
). The
prevalence by province varied from 22.3% in Tibet to 4.8% in Qinghai.
The distribution of hypertension prevalence also followed a
north-south gradient, with the prevalence being higher in the north
than in the south (Fig 2). The overall
prevalences of cigarette smoking and alcohol consumption were 34.5%
and 17.7%, respectively. The average population density was 118
persons per square kilometer, and the average percentage of the
population living in an urban area was 26.2%. The averages for both
these statistics were much lower in the western than in the eastern
provinces.
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There was a striking correlation (r=.838,
P<.001) between the prevalence of hypertension and the
incidence of stroke by province (Fig 3).
After data on Tibet (the province with the highest prevalence of
hypertension and incidence of stroke) were removed from the
analysis, the correlation coefficient between the prevalence of
hypertension and the incidence of stroke remained positive and
significant (r=.531, P=.004). The relationship
between the prevalence of hypertension and mortality from stroke was
similar (r=.841, P<.001 with Tibet included;
r=.470, P=.01 without Tibet). The partial
R2 was .703 for stroke incidence and .707 for
stroke mortality after adjusting for the prevalence of cigarette
smoking and alcohol consumption, population density, and proportion of
urban residents.
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In univariate Poisson regression analysis, the
prevalence of hypertension was positively and significantly related to
the increased risk of stroke (Table 2).
For example, a 10% increase in prevalence of hypertension was
associated with a 2.68-fold higher incidence of stroke and a 2.48-fold
higher stroke mortality. The prevalence of cigarette smoking and
alcohol consumption and the proportion of urban residents were also
associated with an increased incidence and mortality from stroke,
whereas population density was only associated with an increased
mortality from stroke.
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After adjustment for all other covariables listed in the Table,
the relationship between prevalence of hypertension and risk of stroke
became even stronger (Table 3). With a
10% higher prevalence of hypertension, stroke incidence and mortality
increased 2.80- and 2.68-fold, respectively. In
multivariate models, the prevalence of cigarette
smoking was significantly associated only with increased stroke
mortality, not incidence. The prevalence of alcohol consumption was
significantly related to both stroke incidence and mortality after
adjustment for smoking, population density, and proportion of urban
residents.
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After exclusion of data from Tibet, the relationship between prevalence of risk factors and stroke incidence and mortality was similar. For example, the adjusted relative risk for a 10% higher prevalence of hypertension was 2.75 (95% confidence interval [CI], 2.32 to 3.26) for stroke incidence and 1.88 (95% CI, 1.54 to 2.31) for stroke mortality. The adjusted relative risk for a 10% higher prevalence of alcohol consumption was 1.17 (95% CI, 1.08 to 1.28) for stroke incidence and 1.02 (95% CI, 0.93 to 1.12) for stroke mortality. The prevalence of cigarette smoking was no longer significantly associated with stroke rates in multivariate models after excluding Tibet.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Few studies have examined the basis for geographic variation in stroke mortality in the PRC. The present study was able to take advantage of data from national studies of hypertension prevalence and stroke event rates. The PRC National Hypertension Survey and the National Stroke Study provided large representative community samples within each province to estimate the prevalence of hypertension and the incidence and mortality from stroke with substantial precision. National estimates for the prevalence of cigarette smoking and alcohol consumption were also available for use as independent variables in the present study.
In the present analysis, the geographic variation of stroke incidence and mortality in the PRC was striking. Both varied more than eightfold between the provinces with the highest and the lowest rates. Stroke incidence and mortality were in general higher in the provinces in the north than those in the south of the PRC. The geographic distributions for prevalence of hypertension and stroke incidence and mortality were remarkably similar. Prevalence of hypertension explained over 70% of the geographic variability in stroke incidence and mortality in the PRC. A 10% higher prevalence of hypertension was associated with a 2.80-fold higher incidence of stroke and a 2.68-fold higher mortality from stroke, even after adjustment for differences in the prevalence of cigarette smoking and alcohol consumption, population density, and percentage of urban residents. The prevalences of cigarette smoking and alcohol consumption were also associated with the risk of stroke in the present study.
The differences in stroke rates between provinces were not due to differences in assessment or diagnoses of stroke because the 1986 PRC National Stroke Study used standardized survey methods and diagnostic criteria in all provinces. All hospital records and death certifications were reviewed by well-trained neurologists.4 This minimized the possibility of misclassification bias. Although CT scans were not used as a diagnostic criterion for the PRC National Stroke Study, CT data were available for the Sino-MONICA Study. The geographic distribution of stroke rates was similar in both studies.3
Hypertension has been identified as the most important risk factor for stroke, and it has been suggested that improved treatment of hypertension is a major reason for the recent acceleration in the decline in stroke mortality in western countries.13 14 The present study indicates that prevalence of hypertension is a predominant determinant of geographic variation in stroke incidence and mortality in the PRC. In an ecological analysis of 35 populations from the WHO Multinational MONICA Project, prevalence of hypertension was independently associated with stroke mortality.15 However, even when the prevalences of hypertension, cigarette smoking, and high cholesterol were simultaneously taken into account, only 39% of the variation of stroke mortality in men and 35% of the variation in women could be explained,15 which is much lower than in the present study. This discrepancy may be due to the higher relative risk of stroke associated with hypertension in the PRC than in other populations.16
The geographic pattern of stroke and hypertension in the PRC is consistent with the "salt hypothesis," which proposes that high salt intake increases both the risk of hypertension as well as stroke. Several epidemiological studies have documented that dietary salt intake is higher in the north of the PRC than in the south.17 18 19 Tibet has the highest dietary intake of salt in the PRC, over 30 g (513 mmol sodium) per day per person, primarily in the form of salt-flavored tea.20 Tibetans also have the highest prevalence of hypertension, stroke incidence, and stroke mortality. In their study, Sasaki and colleagues21 found a positive ecological relationship between stroke mortality and mean 24-hour urinary excretion of sodium in 17 countries. In the WHO Cardiovascular Diseases and Alimentary Comparison Study, a multicenter epidemiological study conducted in 55 centers in 24 countries, stroke mortality was significantly and positively related to 24-hour sodium excretion in men across the centers.22
Alcohol consumption has been associated with an increased risk of stroke in many studies conducted in populations as well as at the individual level.21 23 24 25 26 An ecological analysis found that alcohol consumption levels per country were significantly and positively correlated with stroke mortality in 17 countries.21 In another ecological analysis, in 46 prefectures in Japan, alcohol intake was significantly correlated with stroke mortality in middle-aged men.26 In the present study, the prevalence of alcohol consumption was associated with an increased incidence and mortality from stroke. However, the effect of alcohol consumption on stroke risk was smaller than that of hypertension.
Cigarette smoking has been accepted as a common risk factor for stroke in western populations.27 28 29 Studies in the PRC have reported controversial results.30 31 Our study identified a significant and independent association between the prevalence of cigarette smoking and stroke mortality. The prevalence of cigarette smoking in the PRC differs by sex: 62% in men and 7% in women aged 15 years or older.7 In the present study, analysis was performed using overall stroke incidence and mortality results because the sex-specific rates by province were not available.10 Given the marked differences in cigarette smoking between men and women, the association between overall prevalence of cigarette smoking and stroke rates observed in this study is almost certainly an underestimate due to misclassification bias.
Urban and rural differences in stroke incidence and mortality have been observed in several studies in the PRC.1 3 4 Population density has also been associated with stroke incidence and mortality rates in the PRC.4 In this analysis, the proportion of urban residents and the population density of the provinces were positively associated with the risk of stroke. These characteristics of provinces are most likely related to stroke because they reflect differences in diet, health habits, and environmental exposures.
Other unmeasured covariables, such as ambient temperature, and other dietary factors may also influence the geographic distribution of stroke in the PRC. In several studies, cold weather has been associated with an increased incidence and mortality from stroke.32 33 The average temperature in Tibet and the northern provinces is lower than in the provinces in the south of the PRC. The consumption of fresh vegetables and fruit is also lower in the north than in the south.34 Some studies have suggested that consumption of vegetables and fruits high in vitamin C and other antioxidants protects against stroke.23 35 36
The present analysis is based on data aggregated for populations rather than data on individuals. Findings from ecological analyses are not necessarily true at the individual level. However, hypertension, alcohol consumption, and cigarette smoking have been major risk factors for stroke in many studies conducted at the individual level.12 23 24 25 27 28 29 30 Moreover, ecological analysis provides a useful way to study determinants for geographic variations of stroke incidence and mortality rates.
In conclusion, the present study confirms that there is marked geographic variation in stroke incidence and mortality in the PRC. Differences in the prevalence of hypertension, cigarette smoking, and alcohol consumption explain much of this variation, with hypertension being the most important factor.
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Acknowledgments |
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This study was supported partially by Outpatient General Research Center grant 5M01RR00722 from the National Institutes of Health (NIH). Computational assistance was received from NIH grant RR00035. Dr He was supported by training grant 5T32HL07024-21 from NIH, National Heart, Lung, and Blood Institute. Dr Klag is an Established Investigator of the American Heart Association.
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Footnotes |
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Reprint requests to Jiang He, MD, PhD, The Welch Center for Prevention, Epidemiology, and Clinical Research, 2024 E Monument St, Suite 2-600, Baltimore, MD 21205-2223.
Received August 21, 1995; revision received September 11, 1995; accepted September 11, 1995.
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