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(Stroke. 1997;28:922-928.)
© 1997 American Heart Association, Inc.

Articles

Socioeconomic Level, Sedentary Lifestyle, and Wine Consumption as Possible Explanations for Geographic Distribution of Cerebrovascular Disease Mortality in Spain

Fernando Rodríguez Artalejo, MD, PhD; Pilar Guallar-Castillón, MD; Juan Luis Gutiérrez-Fisac, MD, PhD; José Ramón Banegas, MD, PhD; Juan del Rey Calero, MD, PhD

From the Department of Preventive Medicine and Public Health, University of the Basque Country (F.R.A.), Vitoria; Department of Preventive Medicine and Public Health, Autonomous University of Madrid (F.R.A., P.G.C., J.L.G.-F., J.R.B., J. del R.C.); Directorate General for Public Health, Ministry of Health (J.L.G-F.); and Cardiovascular Epidemiology Unit, National Center for Epidemiology, Institute of Public Health "Carlos III," Ministry of Health (J.R.B.), Madrid, Spain.

Correspondence to Dr Fernando Rodríguez Artalejo, Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Avda, Arzobispo Morcillo s/n, 28029 Madrid, Spain.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose The geographic distribution of cerebrovascular disease (CVD) mortality in Spain spans a wide range, from provinces where mortality is low (70/100 000) and close to that of the United States and other Anglo-Saxon countries, to others where mortality is high (180/100 000) and more akin to that of Portugal and the Mediterranean and central European countries. This report seeks to identify the socioeconomic and lifestyle factors that most contribute to the geographic pattern of CVD mortality in Spain.

Methods We performed a study using data collected at a provincial level. Mortality data were taken from official vital statistics, and data on risk factors were obtained from surveys of representative large Spanish population samples. Correlation and multiple linear regression analyses were performed on standardized CVD mortality ratios and potential determinants of mortality for the period 1989 to 1993.

Results CVD mortality, unemployment and illiteracy rates, blond cigarette smoking, and sedentary lifestyle proved substantially higher in the south and east (Mediterranean coast) of Spain. Saturated fatty acid intake and wine consumption were both lower in these regions, however. Illiteracy, wine consumption, sedentary lifestyle, high blood pressure, blond cigarette smoking, prevalence of diabetes, and body mass index 30 explained 59% of the variation in CVD mortality. Only illiteracy, sedentary lifestyle, and wine consumption registered a statistically significant relationship (P<.05) with CVD mortality. Whereas lower consumption of wine showed a negative association with CVD mortality, higher consumption revealed a positive association.

Conclusions Socioeconomic level, as measured by illiteracy, sedentary lifestyle, and wine consumption, may partly explain the higher CVD mortality registered for regions situated in the south and east of Spain.

Key Words: epidemiology • geography • mortality • Spain

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
In Spain, as with many developed countries,^{1 2} CVD mortality has progressively declined from 1901 to the present. Nevertheless, CVD was the leading cause of death in Spain in 1993, registering a mortality rate of 107/100 000 inhabitants,³ placing Spain in a middle-ranking position among developed countries. Within the country, however, the geographic distribution of CVD mortality spans a wide range, from provinces where mortality is low (70/100 000) and close to that of the United States and other Anglo-Saxon countries, to others where mortality is high (180/100 000) and more akin to that of Portugal and the Mediterranean and central European countries.⁴ This variation in CVD mortality represents an important potential for prevention provided that the modifiable factors responsible can be identified. This report therefore examines the provincial distribution of CVD mortality in Spain plus known socioeconomic and lifestyle risk factors to identify those that most greatly contribute to the geographic pattern of mortality due to this disease.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The following information was obtained for the 50 provinces of Spain: CVD mortality (ICD-9 codes 430 to 438) data in persons aged 45 to 79 years were gathered from Spanish vital statistics,⁵ and SMRs were computed at a provincial level for the period 1989 to 1993.⁶ National mortality by sex and 5-year age groups was used as standard.

Information on consumption of foodstuffs, nutrients, and tobacco was taken from the 1980 to 1981 Household Budget Survey (Encuesta de Presupuestos Familiares), conducted by the National Statistics Office (Instituto Nacional de Estadística) and National Nutrition Institute (Instituto Nacional de Nutrición), and based on a representative Spanish population sample of 25 000 families.⁷ The survey estimated food and tobacco intake on the basis of the amounts purchased by the families surveyed. Only food consumed at home was included. Food quantities were converted into nutrients by application of standard food composition tables. Salt intake was obtained from a similar survey performed in 1991.⁸ Data on the prevalence of hypercholesterolemia, high blood pressure, sedentary lifestyle, diabetes, and BMI 30 were taken from the 1993 National Health Survey (Encuesta Nacional de Salud de España).⁹ This was an interview-based survey performed by the Ministry of Health, covering a representative 21 000-person sample of the noninstitutionalized Spanish population older than 16 years. Information on hypercholesterolemia, high blood pressure, and diabetes was obtained by the following question: "Has your doctor told you that you are currently suffering from one of the following chronic conditions: high blood pressure, high cholesterol, or diabetes (high sugar)?" Information on sedentary lifestyle was obtained by the question: "What type of physical exercise do you do in your leisure time? Tell me which of these possibilities best describes the major part of your leisure-time activity: (a) I do no exercise at all. I spend most of my leisure time in a sedentary fashion (reading, watching television, going to the cinema, etc); (b) I do some occasional physical or sports activity (walking or riding a bicycle, gardening, easy gymnastics, etc); (c) I do regular physical activity several times a month (tennis, gymnastics, running, swimming, etc); or (d) I do physical training several times a week." Individuals who gave option (a) as their answer were classified as sedentary. BMI (weight [kilograms] divided by height [meters] squared) was calculated on the basis of self-reported information on height and weight, given in response to the following questions: "Could you tell me how much you weigh, without shoes and clothes on?" and "Could you tell me how tall you are without your shoes on?" Finally, information on illiteracy among the segment of the population older than 45 years was taken from the 1981 Population Census,¹⁰ and unemployment rates were obtained from the National Statistics Office's 1981 Active Population Survey (Encuesta de Población Activa).¹¹

Pearson correlation coefficients were computed, and a multiple linear regression analysis of the SMR was performed. Correlation and regression analyses were weighted by the proportion of CVD deaths for each province over total CVD deaths in Spain. Statistical analysis was performed with the use of the SAS software package.¹²

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
CVD mortality in Spain showed a coefficient of variation of 31.52%, with 24 of the country's 50 provinces registering an SMR significantly different (P<.05) from the national mean (SMR=100). CVD mortality was higher in provinces lying in the south and east (Mediterranean coast) of the country (Fig 1).

View larger version (67K): [in this window] [in a new window]   Figure 1. CVD mortality (1989-1993), saturated fatty acid intake (1980-1981), blond cigarette smoking (1980-1981), and prevalence of self-reported high blood pressure (1993) in Spain. Quintiles of provincial distribution are shown. The upper section of each map represents the north of Spain.

Wine consumption proved to be the risk factor for CVD with greatest provincial variability (Table 1). Alcohol intake; consumption of beef, legumes, and blond cigarettes; and the percentage of illiteracy among the segment of the population older than 45 years registered coefficients of variation in excess of 40%. Whereas intake of saturated fatty acids and wine were lower in the southern provinces, blond cigarette smoking, sedentary lifestyle, unemployment, and illiteracy among those older than 45 years proved to be relatively higher. Prevalence of high blood pressure showed no defined geographic pattern (Figs 1 and 2).

View this table: [in this window] [in a new window]   Table 1. Correlations Between CVD Mortality (1989-1993) and Socioeconomic and Lifestyle Risk Factors in 50 Provinces of Spain

View larger version (62K): [in this window] [in a new window]   Figure 2. Wine consumption (1980-1981), percentage of unemployment (1981), percentage of illiteracy among segment of the population older than 45 years (1981), and percentage of self-reported sedentary lifestyle (1993) in Spain. Quintiles of provincial distribution are shown. The upper section of each map represents the north of Spain.

Blond cigarette smoking, prevalence of sedentary lifestyle, BMI 30, and percentage of unemployment and illiteracy among the segment of the population older than 45 years correlated significantly (P<.05) and positively with CVD mortality, while consumption of milk, meat, beef, eggs, wine, and saturated fats showed a negative correlation (Table 1). Salt intake, prevalence of hypercholesterolemia and high blood pressure, and the remaining variables registered correlations that failed to attain statistical significance.

To ascertain the independent contribution of the above factors to CVD mortality, a multiple linear regression model was constructed in which the dependent variable was the SMR for CVD. It was decided that saturated fats would not be included in the model, in the absence of unequivocal evidence in the literature of their association with CVD mortality.¹³ On the same grounds and by reason of their high correlation with saturated fats (Table 2), consumption of milk, meat, beef, and eggs were likewise not included in the model. The jobless rate was also excluded because it showed a marked correlation with illiteracy among the segment of the population older than 45 years (Table 2) and because there is evidence in the literature to show that its association with cardiovascular disease mortality is of a lower magnitude than that of education.¹⁴ Prevalence of high blood pressure and diabetes were included, however, because both are important risk factors for CVD,^{13 15 16 17} despite the fact that they failed to attain statistical significance in the crude analysis.

View this table: [in this window] [in a new window]   Table 2. Correlations Between Principal Risk Factors for CVD in Spain

Taken together, the variables in the model explained 59% of the variation in CVD mortality across Spain (Table 3). Illiteracy in the segment of the population older than 45 years was the sole variable to show a significant and independent association with CVD mortality in Spain. The correlation coefficient for two variables, ie, blond cigarette smoking and BMI 30, registered a sign contrary to that observed in the crude analysis, owing to both the high correlation between these variables and illiteracy among those older than 45 years and the stronger association between the latter variable and CVD mortality. Hence, and since part of the possible effect of socioeconomic status (as gauged by illiteracy) on CVD mortality is probably mediated by other variables, it was decided that a new model should be constructed excluding illiteracy (Table 4). The variables in the model jointly served to explain 40% of the variation in CVD mortality in Spain. Only consumption of wine and sedentary lifestyle registered a statistically significant relationship (P<.05) with CVD mortality in Spain. Whereas lower consumption of wine showed a negative association with CVD mortality, higher consumption (quadratic term in the model) revealed a positive association. Those provinces with a greater prevalence of a sedentary lifestyle registered a higher level of CVD mortality.

View this table: [in this window] [in a new window]   Table 3. Multiple Linear Regression Analysis of SMR for CVD in Spain in Model Including the Variable Percentage of Illiteracy in Those >45 y

View this table: [in this window] [in a new window]   Table 4. Multiple Linear Regression Analysis of the SMR for CVD in Spain in Model Excluding the Variable Percentage of Illiteracy in Those >45 y

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
This study suggests that socioeconomic level, as approximated by the percentage of illiteracy among the segment of the population older than 45 years, is the variable that best explains the geographic distribution of CVD mortality in Spain. The lower wine consumption and more accentuated sedentary lifestyle of the southern and eastern regions of Spain may also explain the higher CVD mortality in these regions of the country.

It is known that CVD mortality exhibits a considerable variation according to social class (the higher the class, the lower the CVD mortality).¹⁷ This association has also been observed at an ecological level, both in the international literature^{18 19 20} and in individual studies undertaken in Spain.^{21 22} The association could be mediated by genetic, physiological, behavioral, or environmental variables.¹⁷ Our results suggest that the effect of socioeconomic status on geographic distribution of CVD mortality could in part be related to consumption of wine and sedentary lifestyle. In Spain, there is a positive dose-response relationship between the frequency of moderate alcohol consumption and socioeconomic status as measured by the level of education attained, while the dose-response relationship is negative for excessive consumption of alcohol and level of education attained.²³ Furthermore, the degree of physical leisure activity tends to be greater among persons at the highest socioeconomic level in Spain²⁴ as well as in other countries.²⁵

The relationship between alcohol consumption and CVD is not clear in the literature on the subject.¹³ In part, this is due to the fact that many cohort and case-control studies have included lifetime and newer teetotalers in the same group, when the effect of alcohol may be different between the two categories. Ecological studies published to date have failed to furnish consistent results. St Leger et al²⁶ were thus unable to detect a linear association between alcohol consumption and CVD mortality in 18 (mostly European) countries. In contrast, Ueshima et al²⁷ found quite a strong positive association on using comparable data from 46 prefectures in Japan and adjusting for salt intake and a number of socioeconomic factors. Similarly, Sasaki et al²⁸ reported a positive association between alcohol consumption and CVD mortality in a correlational population-based study embracing 17 countries. Although the relationship between physical activity and risk of CVD has not been extensively studied, the information available is fairly consistent and points to an inverse and significant relationship between the two variables.¹³

Nevertheless, assessment of the results of this study calls for a certain measure of prudence, inasmuch as neither the study design nor data can be considered optimum. First, overall CVD mortality data were used, without any distinction as to whether deaths were ischemic or hemorrhagic in origin, when the risk factors may be partially different between the two.^{13 29} Indeed, some studies specifically suggest that the dose-response relationship between alcohol consumption and CVD mortality would be positive and continuous in the case of hemorrhagic origin yet J-shaped in the case of ischemic origin.³⁰ It should be noted, however, that most CVD deaths in Spain are ischemic in origin.^{1 4}

Second, this was an ecological study. Our results, which are consistent with those from other countries such as the United States,³¹ suggest that distribution of known risk factors for CVD—prevalence of high blood pressure and smoking, in particular—does not explain the spatial distribution of the disease in Spain. However, this does not mean that high blood pressure and smoking are entirely devoid of influence on the risk of CVD among the Spanish population. This influence depends on the level of analysis.³² There is ample evidence that high blood pressure and smoking raise the risk of CVD at an individual level.^{13 17} This report in no way seeks to extend its inferences to levels of aggregation beyond that of the provincial geography of Spain.

Third, data on socioeconomic and lifestyle variables were drawn from a number of years with the ensuing possibility that, in several cases, such data may not allow for an adequate induction time for their effect on CVD. However, there is evidence of a degree of temporal stability in the data, since the south of Spain has traditionally encompassed less socially favored regions, and changes in lifestyle habits (eg, diet, physical activity) tend to require long periods of time.

Fourth, some data on lifestyle habits and biological variables (high blood pressure, hypercholesterolemia, diabetes, weight, and height) were self-reported and not accompanied by objective measurements. Several variables might have been underassessed.^{33 34 35} Nevertheless, there was no evidence that the error might be different across provinces.

Finally, no account was taken of the existence of interprovincial differences in the availability and accessibility of high-technology healthcare services in Spain.³⁶ Advances made during recent years in the treatment of CVD have been modest, so that any contribution thereof to geographic distribution of CVD would necessarily be small. However, an ecological study performed in districts of Catalonia (northwestern Spain) has shown a negative relationship between degree of blood pressure control and CVD mortality.³⁷

From the standpoint of CVD prevention, our findings are relevant for a number of reasons: first, they stress the importance of reducing socioeconomic inequalities in the distribution of risk factors, such as excessive consumption of wine and sedentary lifestyle; second, the same factors responsible for the geographic distribution of CVD are those responsible for that of ischemic heart disease. In an earlier study, we observed that ischemic heart disease mortality was likewise higher in the south and east of Spain and that socioeconomic level and wine consumption were associated with a higher ischemic heart disease mortality in regions along the Mediterranean seaboard.³⁸ There is therefore a reasonable likelihood that the same prevention policies might serve to reduce mortality from both CVD and ischemic heart disease, which are the first and second leading causes of death in Spain, respectively.

	Selected Abbreviations and Acronyms

 

BMI = body mass index CVD = cerebrovascular disease ICD-9 = International Classification of Diseases, 9th Revision SMR = standardized mortality ratio

	Acknowledgments

 
This study was supported in part by a research grant from Merck Sharp and Dohme. We thank Michael Benedict for translating this report into English.

Received November 19, 1996; revision received January 21, 1997; accepted February 14, 1997.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 
1. Barrado-Lanzarote MJ, de Pedro-Cuesta J, Almazán Isla J. Stroke mortality in Spain 1901-1986. Neuroepidemiology. 1993;12:148-157.[Medline] [Order article via Infotrieve]

2. Thom TJ, Epstein FH, Feldman J, Leaverton PE, Wolz M. Total Mortality and Mortality From Heart Disease, Cancer and Stroke From 1950 to 1987 in 27 Countries. Bethesda, Md: National Heart, Lung, and Blood Institute; 1992. Publication NIH 92-3088.

3. Instituto Nacional de Estadística. Defunciones Según la Causa de Muerte. 1993. Madrid, Spain: Instituto Nacional de Estadística; 1996.

4. Barrado-Lanzarote MJ, Almazán-Isla J, Medrano-Albero MJ, de Pedro-Cuesta J. Spatial distribution of stroke mortality in Spain, 1975-1986. Neuroepidemiology. 1995;14:165-173.[Medline] [Order article via Infotrieve]

5. Instituto Nacional de Estadística. Movimiento Natural de la Población Española: Defunciones Según la Causa de Muerte: Años 1989-1993. Madrid, Spain: Instituto Nacional de Estadística; 1992-1996.

6. Breslow NE, Day NE. Rates and rate standardization. In: Breslow NE, Day NE. Statistical Methods in Cancer Research: The Design and Analysis of Cohort Studies. Lyon, France: International Agency for Research on Cancer; 1987:48-81.

7. Instituto Nacional de Estadística. Encuesta de Presupuestos Familiares 1980-1981: Tomo V, 1^a y 2^a parte. Madrid, Spain: Instituto Nacional de Estadística; 1985.

8. Instituto Nacional de Estadística. Encuesta de Presupuestos Familiares 1990-1991: Volumen II. Madrid, Spain: Instituto Nacional de Estadística; 1994.

9. Ministerio de Sanidad y Consumo. Encuesta Nacional de Salud de España 1993. Madrid, Spain: Ministerio de Sanidad y Consumo; 1995.

10. Instituto Nacional de Estadística. Censo de Población de 1981; Tomo I, Volumen I: Resultados Nacionales: Características de la Población. Madrid, Spain: Instituto Nacional de Estadística; 1985.

11. Instituto Nacional de Estadística. Encuesta de Población Activa: Año 1981. Madrid, Spain: Instituto Nacional de Estadística; 1981.

12. SAS/STAT Guide for Personal Computers, Version 6.03. Cary, NC: SAS Institute; 1988.

13. Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke. N Engl J Med. 1995;333:1392-1400.[Free Full Text]

14. Kaplan GA, Keil JE. Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation. 1993;88:1973-1997.[Abstract/Free Full Text]

15. MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J. Blood pressure, stroke, and coronary heart disease, part 1: prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990;335:765-774.[Medline] [Order article via Infotrieve]

16. Prospective Studies Collaboration. Cholesterol, diastolic blood pressure, and stroke: 13000 strokes in 450000 people in 45 prospective cohorts. Lancet. 1995;346:1647-1653.[Medline] [Order article via Infotrieve]

17. Marmot MG, Poulter NR. Primary prevention of stroke. Lancet. 1992;339:344-347.[Medline] [Order article via Infotrieve]

18. Siegel PZ, Deeb LC, Wolfe LE, Wilcox D, Marks JS. Stroke mortality and its socioeconomic, racial and behavioral correlates in Florida. Public Health Rep. 1993;108:454-458.[Medline] [Order article via Infotrieve]

19. Nayha S. Geographical variations in cardiovascular mortality in Finland, 1961-1985. Scand J Soc Med. 1989;40(suppl):1-48.

20. Mackenbach JP, Kunst AE, Looman CW. Cultural and economic determinants of geographical mortality patterns in the Netherlands. J Epidemiol Community Health. 1991;45:231-237.[Abstract/Free Full Text]

21. Regidor E, de Mateo S, Gutiérrez-Fisac JL, Rodríguez C. Diferencias socioeconómicas en mortalidad en ocho provincias españolas. Med Clin (Barc). 1996;106:285-289.[Medline] [Order article via Infotrieve]

22. Regidor E, Gutiérrez-Fisac JL, Rodríguez C. Increased socioeconomic differences in mortality in eight Spanish provinces. Soc Sci Med. 1995;41:801-807.

23. Regidor E, Gutiérrez-Fisac JL, Rodríguez C. Diferencias y Desigualdades en Salud en España. Madrid, Spain: Díaz de Santos; 1994.

24. Regidor E, Rodríguez C, Gutiérrez-Fisac JL. Indicadores de Salud: Tercera Evaluación en España del Programa Regional Europeo Salud para Todos. Madrid, Spain: Ministerio de Sanidad y Consumo; 1995:227-233.

25. Ford ES, Merritt RK, Health GW, Power KE, Washburn RA, Kriska A, Haile G. Physical activity behaviors in lower and higher socioeconomic status populations. Am J Epidemiol. 1991;133:1246-1256.[Abstract/Free Full Text]

26. St. Leger AS, Cochrane AL, Moore F. Factors associated with cardiac mortality in developed countries with particular reference to the consumption of wine. Lancet. 1979;1:1017-1020.[Medline] [Order article via Infotrieve]

27. Ueshima H, Ohsaka T, Asakura S. Regional differences in stroke mortality and alcohol consumption in Japan. Stroke. 1986;17:19-24.[Abstract/Free Full Text]

28. Sasaki S, Zhang XH, Kesteloot H. Dietary sodium, potassium, saturated fat, alcohol, and stroke mortality. Stroke. 1995;26:783-789.[Abstract/Free Full Text]

29. Thrift AG, Donnan GA, McNeil JJ. Epidemiology of intracerebral hemorrhage. Epidemiol Rev. 1995;17:361-381.[Free Full Text]

30. Camargo CA Jr. Moderate alcohol consumption and stroke: the epidemiological evidence. Stroke. 1989;20:1611-1626.[Abstract/Free Full Text]

31. Lanska DJ, Kuller LH. The geography of stroke mortality in the United States and the concept of a stroke belt. Stroke. 1995;26:1145-1149.[Free Full Text]

32. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14:32-38.[Abstract/Free Full Text]

33. Bowlin SJ, Morrill BD, Nafziger AN, Jenkins PL, Lewis C, Pearson TA. Validity of cardiovascular disease risk factors assessed by telephone survey: the Behavioral Risk Factor Survey. J Clin Epidemiol. 1993;46:561-571.[Medline] [Order article via Infotrieve]

34. Nieto García FJ, Bush TL, Kely PM. Body mass definitions of obesity: sensitivity and specificity using self-reported weight and height. Epidemiology. 1990;1:146-152.[Medline] [Order article via Infotrieve]

35. Quiles Izquierdo J, Vioque J. Validez de los datos antropométricos declarados para la determinación de la prevalencia de obesidad. Med Clin (Barc). 1996;106:725-729.[Medline] [Order article via Infotrieve]

36. Aracil E, Banegas JR, del Llano J, del Llano M, de la Mata I, Gol J, González J, Villar F. Sistema Gráfico de Información Sanitaria en España. Madrid, Spain: MSD; 1996.

37. Treserras R, Serra-Majem L, Canela J, Armario P, Pardell H, Rue M, Salleras L. Ecological association between hypertension and stroke in Catalonia (Spain): development and use of an ecological regression model. J Hum Hypertens. 1990;4:300-302.[Medline] [Order article via Infotrieve]

38. Rodríguez Artalejo F, Banegas JR, García Colmenero C, del Rey Calero J. Lower consumption of wine and fish as a possible explanation for higher ischemic heart disease mortality in Spain's Mediterranean region. Int J Epidemiology. 1996;25:1196-1201.[Abstract/Free Full Text]

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