(Stroke. 1998;29:1366-1372.)
© 1998 American Heart Association, Inc.
Opposing National Stroke Mortality Trends in Poland and for African Americans and Whites in the United States, 1968 to 1994
Mark W. Massing, MD, MPH;
Stefan L. Rywik, MD, PhD;
Bogdan Jasinski, MSC;
Teri A. Manolio, MD, MHS;
O. Dale Williams, PhD;
Herman A. Tyroler, MD
From the Department of Epidemiology, University of North Carolina School
of Public Health, Chapel Hill (M.W.M., H.A.T.); Department of Cardiovascular
Epidemiology and Prevention of Cardiovascular Disease, National Institute of
Cardiology, Warsaw, Poland (S.L.R., B.J.); Division of Epidemiology and
Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, Md
(T.A.M.); and Departments of Medicine and Biostatistics, University of Alabama
at Birmingham (O.D.W.).
Correspondence to Mark W. Massing, MD, MPH, Department of Epidemiology, UNC School of Public Health, Suite 306, 137 E Franklin St, Chapel Hill, NC 27514. E-mail mark_massing{at}unc.edu
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Abstract
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Background and Purpose—The United
States (US) has experienced declines in stroke mortality in contrast to
the increases reported for Poland. As part of the Poland and US
Agreement on Cardiovascular and Cardiopulmonary
Research, stroke mortality trends in Polish and US subpopulations were
compared in the context of cross-population differences in competing
causes of death and determinants of stroke.
Methods—Age-adjusted annual stroke,
cardiovascular disease (CVD), non-CVD, and all-cause
mortality rates were determined for men and women aged 35 to 64 and 65
to 74 years from 1968 to 1994 for African Americans and US whites and
in Poland. Mean annual percent changes of mortality rates were
estimated during 1968 to 1980 and 1981 to 1994 with the use of
piecewise log-linear regression.
Results—US stroke mortality rates declined 3.7% to 4.8%
annually during 1968 to 1980 and 2.0% to 3.1% during 1981 to 1994,
with similar declines in each ethnic, gender, and age group. Polish
rates increased 3.3% to 5.5% annually for all age-gender groups in
Poland during 1968 to 1980. Polish men aged 35 to 64 experienced
increasing rates during 1981 to 1994 (1.6% annually), while Polish
women and older men experienced slight declines or little change. Only
Polish men aged 35 to 64 years exhibited increases in stroke, CVD, and
non-CVD mortality rates during both time intervals.
Conclusions—Poland and the US experienced opposing stroke
mortality rate trends between 1968 and 1994. These national and ethnic
trends occurring in just one generation suggest major effects of
lifestyle, socioenvironmental, and/or medical care determinants.
Key Words: cardiovascular diseases • cerebrovascular disorders • epidemiology • mortality
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Introduction
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Trends for stroke and
total CVD mortality have been strikingly different in Poland and other
central or eastern European countries compared with the
US.1 2 3 4 5 In general, stroke and CVD rates in
Poland have been increasing contemporaneously with declines in the US.
Although international variation in stroke and CVD mortality rates is
not well understood, temporal and cross-population variations in
lifestyle, socioenvironmental, and medical care determinants within
countries and between countries may provide a partial
explanation.6 7 8 9 10 11 12 13 Cross-population differences in
genetic susceptibility to CVD and CVD risk factors have also been
suggested.14 15 16
As part of the Poland and US Agreement on
Cardiovascular and Cardiopulmonary Research
between the Poland National Institute of Cardiology and
the US National Heart, Lung, and Blood
Institute,17 this report compares stroke
mortality rates in the two countries from 1968 to 1994. Stroke
mortality was selected because of its sensitivity to a number of
modifiable risk factors,18 particularly
hypertension,19 20 and because of its relation to
social and demographic characteristics of communities and
individuals.21 22 23 An important objective of this
study was to contrast stroke mortality trends between the two countries
across strata of gender, age, and ethnicity (US only) because the
different stroke mortality rates experienced among these populations
suggest that trends may also differ. We evaluate these contrasts in the
context of competing causes of death and previous reports of
cross-population variation in the determinants of stroke and CVD.
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Subjects and Methods
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Stroke, CVD, non-CVD, and all-cause mortality rates and trends
in Poland and for African Americans and whites in the US from 1968 to
1994 were calculated for men and women aged 35 to 64 years and 65 to 74
years. Vital statistics for the US were stratified into African
American and white subpopulations because of the markedly different
stroke mortality experiences of these two
groups.3 National mortality and population data
were obtained from the Main Statistical Office in
Poland24 and from the US National Center for
Health Statistics Compressed Mortality File.25
Five-year age strata from the Polish data were aggregated to match the
10-year age strata provided for the US. Direct age standardization was
performed for subjects aged 35 to 64 years with weights determined
previously from Segi's world population.26
Underlying cause of death in Poland was classified in accordance with
the seventh27 (1968 to 1969),
eighth28 (1970 to 1979), and
ninth29 (1980 to 1994) revisions of the
International Classification of Diseases, Traumas, and Causes of
Death. Underlying cause of death in the US was classified in
accordance with the Eighth Revision International Classification
of Diseases, Adapted for Use in the United
States30 (1968 to 1978) and the ninth revision of
the ICD31 (1979 to 1994). Deaths attributed to
stroke were identified as seventh revision rubrics 330 through 334
(vascular lesions affecting the central nervous system) and eighth and
ninth revision rubrics 430 through 438 (cerebrovascular disease).
Deaths attributed to CVD were identified as seventh revision rubrics
330 through 334 and 400 through 468 and eighth and ninth revision
rubrics 390 through 459. Deaths attributed to non-CVD causes included
all rubrics other than those for CVD.
Mortality rate trends were evaluated with the use of piecewise
log-linear regression techniques within strata of cause, country, age,
gender, and ethnicity (US only) for the time periods 1968 through 1980
and 1981 through 1994. These time intervals were chosen to be
contemporaneous with previously reported periods of accelerating and
decelerating rates of decline in US stroke mortality
rates3 32 and are not intended to
represent best-fit curves. The log-linear model assumes
constant proportional or relative change over time and has been used in
previous studies of stroke mortality rate
trends.22 32 Regression modeling was performed
with the SAS REG procedure.33 Predicted mortality
rates from regression models were used to calculate mean annual percent
change in mortality rates during each time interval.
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Results
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Included in this study were approximately 300 000 deaths
attributed to stroke in Poland, a similar number of stroke deaths for
African Americans, and 1.3 million stroke deaths for US whites
occurring from 1968 to 1994. These stroke deaths accounted for 6.6%,
8.5%, and 5.8% of all deaths occurring in populations aged 35 to 74
years in Poland, for African Americans, and for US whites,
respectively, during this time interval. Annual mortality rates,
expressed as deaths per 100 000 population, are illustrated in Figures 1
and 2.
Consistent with previous reports, stroke mortality rates were
higher for men than for women, for African Americans than for US
whites, and for older persons than for younger persons in each country.
Mortality rates in both figures are shown on a log scale to facilitate
comparisons of relative trends among these populations with very
different mortality experiences.
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Figure 1. Age-adjusted stroke, CVD, non-CVD, and all-cause
mortality per 100 000 population for US whites, African Americans
(US-AA), and in Poland from 1968 to 1994 for men and women, age of
death 35 to 64 years (log scale).
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Figure 2. Stroke, CVD, non-CVD, and all-cause mortality per
100 000 population for US whites, African Americans (US-AA), and in
Poland from 1968 to 1994 for men and women, age of death 65 to 74 years
(log scale).
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African American and US white men and women aged 35 to 64 years (Figure 1
) experienced decreasing stroke mortality rates between 1968 and 1994.
In contrast, stroke mortality rates increased in Poland from 1968 to
1980 for each gender in this age group. Stroke mortality rates
continued to increase for Polish men during the late 1980s and early
1990s but peaked and declined slightly for Polish women. CVD mortality
rates for men and women aged 35 to 64 years generally decreased for
African Americans and US whites and increased in Poland. However, a
striking decrease in CVD mortality rates of nearly 20% occurred for
both men and women aged 35 to 64 years in Poland during the early
1990s. Non-CVD mortality rates for persons aged 35 to 64 years in each
US ethnic-gender group declined somewhat during the 1970s and early
1980s and stabilized thereafter. In contrast, non-CVD rates in Poland
generally increased for men and changed little for women. All-cause
mortality rates from 1968 to 1994 for persons aged 35 to 64 years
decreased for each US ethnic-gender group, increased for Polish men,
and changed little for Polish women, except for a recent decrease in
the early 1990s.
Stroke mortality rates for African-American and US white men and women
aged 65 to 74 years (Figure 2) decreased between 1968 and 1994. Stroke
rates for men and women of this age in Poland generally increased from
1968 to the late 1970s and fluctuated thereafter. CVD mortality rates
for persons aged 65 to 74 years decreased in each US ethnic-gender
group from 1968 to 1994. These rates in Poland generally increased
during the 1970s and early 1980s and subsequently changed little for
men and declined for women. Non-CVD mortality rates for persons aged 65
to 74 years changed little in the US for each ethnic-gender group
except for increases in women during the 1980s and 1990s. In contrast,
non-CVD rates declined slightly in Poland, especially for women.
All-cause mortality rates from 1968 to 1994 for ages 65 to 74 years
generally decreased in the US for each ethnic-gender group.
Contemporaneously, all-cause mortality changed little in Poland for men
and women in this age group.
The mean annual percent changes in stroke, CVD, non-CVD, and all-cause
mortality rates in Poland and for African Americans and US whites for
the time periods 1968 to 1980 and 1981 to 1994 are presented in
the Table. The US populations experienced
dramatic declines in stroke mortality rates of approximately 60% to
70% during this 27-year period, varying little by age, ethnicity, and
gender. In contrast, Polish rates increased approximately 20% to 100%
from 1968 to 1994, depending on age and gender. Relatively rapid stroke
mortality rate decreases occurred between 1968 and 1980 in the US,
ranging from 3.7% to 4.8% per year. The decline in US stroke
mortality rates subsequently slowed to 2% to 3% annually from 1981 to
1994. Although relative declines in the US were similar for each
ethnic, gender, and age group, absolute declines varied considerably
and were higher in populations experiencing higher stroke mortality
rates. Each age-gender group in Poland experienced increasing stroke
mortality rates from 1968 to 1980, averaging from 3.3% per year for
women aged 65 to 74 years to 5.5% per year for men aged 35 to 64
years. Polish stroke mortality rates changed little from 1981 to 1994
for women aged 35 to 64 years and men aged 65 to 74, declined for women
aged 65 to 74 years, and continued upward for men aged 35 to 64 years.
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Table 1. Mean Annual Percent Change in Stroke, CVD, Non-CVD, and
All-Cause Mortality Rates for Poland, US Whites, and African Americans
During 1968–1980 and 1981–1994 in Men and Women Aged 35–64 and
65–74 Years
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Discussion
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These results illustrate a pattern of opposing national trends in
stroke mortality rates between the US and Poland from 1968 to 1994. The
period of accelerated decline in stroke mortality rates during the
1970s for African Americans and US whites was contemporaneous with a
period of relatively rapid increases in Poland. Beginning in the early
1980s, US white and African American populations experienced continued
but less rapid declines in stroke mortality rates, which may have
culminated in a leveling of the decline in the 1990s. Similarly, stroke
mortality rates in Poland began to stabilize during the 1980s for all
populations studied except for Polish men aged 35 to 64 years, who
experienced generally persistent increases in stroke mortality rates.
Indeed, these Polish men experienced increases in CVD, non-CVD, and
all-cause mortality rates concurrent with their relatively large
increases in stroke mortality rates from 1968 to 1994. As a result,
they have become increasing more likely to experience death due to CVD
and non-CVD causes relative to women, leading to a widening mortality
rate gap between genders in Poland.
Previous studies have suggested that temporal, geographic, and ethnic
variation in the distribution of known risk factors may partially
explain cross-population differences in stroke and CVD mortality
rates.6 7 8 9 10 11 12 It is likely that differential
exposures to risk factors and to effective preventive interventions in
Polish and US populations may explain at least a portion of the
observed disparities in stroke and CVD mortality rate levels and
trends. Prominent among the recognized risk factors are hypertension,
cigarette smoking, ethanol consumption, diabetes, physical inactivity,
dietary fat intake, and hypercholesterolemia.
Substantial differential exposures to risk factors have been
demonstrated over time and between and within
nations.9 12 34 35 36 37 38 Supportive of the explanatory
role of avoidable risk factors and health behaviors is a study of
Seventh Day Adventists living in Poland who were observed to experience
much lower exposures to tobacco and ethanol while enjoying markedly
higher life expectancies compared with the Polish population in
general.39 In addition, the mortality rate gap
between gender groups observed in the Polish population was not seen in
the Seventh Day Adventists group.39
An association of hypertension with stroke and with other
manifestations of CVD has been well
established.40 A previous report comparing data
collected from the Polish Pol-MONICA Study from 1983 to 1984 with data
from the US Lipid Research Clinics Program Prevalence Study from 1972
to 1976 revealed markedly higher systolic blood pressures
(approximately 10 to 20 mm Hg higher) in Poland than in the
US.17 A recent study of hypertension comparing
Pol-MONICA participants with those from the US
Atherosclerosis Risk in Communities (ARIC) cohort
demonstrated that mean systolic blood pressure remained more
than 15% higher for Polish samples than for the US in the late
1980s.41 The strikingly higher prevalence and
poorer control of hypertension in Poland compared with the US were
attributed to the success of US hypertension control
programs.41 It has also been shown that African
Americans experience higher hypertension prevalence rates than US
whites.42 On the basis of data from the US Third
National Health and Nutrition Examination Survey (NHANES III, 1988 to
1991), the age-adjusted prevalence of hypertension (ie,
systolic blood pressure 
140 mm Hg, and/or
diastolic blood pressure 90 mm Hg, and/or the use
of antihypertensive medications) in non-Hispanic African Americans
(32.4%) was almost 40% greater than that of non-Hispanic US whites
(23.3%).43 Treatment and control rates in the US
were similar for these ethnic groups.43 Thus,
there are important national and ethnic differences in blood pressure
levels and in hypertension prevalence and control that are
consistent with the observed differences in stroke mortality
rates among these populations.
The efficacy of hypertension treatment and control in the reduction of
stroke mortality at the level of the individual has been
demonstrated.44 However, the impact of
hypertension treatment and control on US stroke mortality rates remains
controversial. It is widely believed that public health interventions
against hypertension importantly contributed to the accelerated decline
in US stroke mortality rates observed during the
1970s.45 Indeed, declines in blood pressure in
both African American and US white cohorts and US improvements in
hypertension awareness, treatment, and control did occur during the
1970s and 1980s contemporaneously with accelerated declines in US
stroke mortality rates.10 11 46 Nevertheless,
some studies have suggested that little of the accelerated decline was
due to progress in the treatment and control of
hypertension.47 48
Differences in cigarette smoking prevalence rates and consumption are
consistent with the observed stroke and CVD mortality rate
disparities and trends. Consumption of tobacco in Poland dramatically
increased during the 1970s and early 1980s, then stabilized at a level
that remains one of the highest in the
world.49 50 51 Increasing tobacco consumption in
Poland has been accompanied by predictable increases in cancer
mortality rates, especially in men, no doubt exacerbating the upward
non-CVD mortality rate trends noted previously for men aged 35 to 64
years.49 Reductions in upward stroke mortality
trends in Poland during the 1980s and 1990s may have been partially due
to the contemporaneous stabilization of tobacco consumption. Although
the prevalence of cigarette smoking is lower and declining in the US
population compared with Poland, African American men have experienced
consistently higher smoking prevalence relative to African
American women and US whites since at least
1965.52 In both Poland and the US, the prevalence
of smoking has been lower for women than for men. In 1994, the
prevalence of cigarette smoking for African American men and women and
for US white men and women aged 18 years and older was 34%, 21%,
28%, and 24%, respectively.52 The prevalence of
smoking in Polish women has been similar to that of US women, but
smoking prevalence for Polish men has been almost twice that of US
men.34 38 51
Trends in the consumption of ethanol and animal fat in Poland and in
the US may have contributed to observed changes in stroke and CVD
mortality rates. Per capita ethanol consumption doubled in Poland from
1962 to 1978, abruptly declined by approximately 50% in the early
1980s, and may have increased through the early
1990s.53 Per capita ethanol consumption in the US
declined by approximately 12% through the
1980s.12 54 Animal fat consumption steadily
increased in Poland through the 1970s and fluctuated at high levels in
the 1980s.50 55 The discontinuation of government
subsidies for animal products in 1989 to 1990, the intensive
advertising for soft margarine, and the initiation of public health
interventions such as television and radio programs targeting CVD
prevention and health promotion was associated with a 50% decline in
butter consumption and declines in percentage of energy derived from
saturated fats in Poland during the late 1980s and early
1990s.50 56 Perhaps more than coincidentally,
Polish CVD mortality rates, previously increasing, showed marked
declines in the early 1990s. It should be noted, however, that stroke
mortality rates in Poland did not exhibit similar declines during the
1990s. Since CHD is the major contributor to CVD mortality rates, the
downward trend of CVD mortality rates during the early 1990s was likely
more heavily influenced by CHD rather than stroke mortality. This
suggests a prominent role for CHD in the recent CVD mortality rate
declines, and if reduction in animal fats was responsible, it appears
that stroke mortality in Poland is not as strongly associated with
animal fat consumption as is CHD mortality. Declines in the consumption
of animal fats have been observed in the US contemporaneously with
declines in serum cholesterol levels since at least the
1970s.12 35 57
Diabetes mellitus and physical inactivity have been identified as
important risk factors for stroke.58 59 60 61 62 It has
been suggested that these two risk factors are associated with each
other through pathways that may involve
obesity.63 64 Results from the National Health
Interview Survey in the US indicate that the age-adjusted prevalence of
self-reported diagnosed diabetes increased 15% from 1980 to
1994.65 A high prevalence of self-reported
overweight (21%) and sedentary lifestyle (58%) has been found in the
US (1988) in the Behavioral Risk Factor Surveillance
System.66 The paradoxical increase in the
prevalence of obesity with contemporaneous declines in dietary fat
intake in the US during the 1970s and 1980s has been attributed to
declines in total physical activity energy
expenditure.67 The prevalence of diabetes in
African Americans is higher than in US whites, consistent with
observed ethnic differences in stroke
mortality.65 68 Increasing trends in diabetes,
physical inactivity, and obesity may partially explain the decelerating
rate of decline in stroke mortality in the US.
Low socioeconomic status of individuals and adverse community
socioenvironmental conditions have been directly related to stroke and
CVD and may partially explain mortality rate disparities between the US
and Poland and between US ethnic
groups.13 22 69 70 71 72 Important socioeconomic and
political changes that have occurred in Poland have transformed its
social structure and influenced patterns of
disease.72 73 74 75 76 The US has experienced rapid
socioeconomic development in its rural southeastern "Stroke Belt"
region, which may have contributed to important declines in stroke
mortality rates in that region and for the nation as a
whole.77 78 Increasing inequalities in the
distribution of income may have adversely influenced mortality rates in
the US.70 79
It is likely that observed mortality rate trends have been influenced
by trends in diagnostic custom and recording
practices. Studies of the accuracy of US stroke death certification
compared with autopsy diagnoses and standardized diagnoses using
medical records reveal positive predictive values for death
certificate diagnoses ranging from approximately 80% to 100% and
sensitivities in the range of 60% to 70%.80 81 82 83 84
One study found that the positive predictive value and sensitivity of
stroke death certificate diagnoses improved from 1970 to
1980.84 A trend of improving sensitivity in the
death certificate diagnosis of stroke could diminish the decline of
stroke mortality rates. An evaluation of case ascertainment in the
World Health Organization MONICA Stroke Study has revealed that death
certificate diagnoses in Poland agreed with MONICA Stroke Register
diagnoses in 64% of the stroke cases.85 In the
presence of similarity of trends among stroke, CVD, and all-cause
mortality rates as observed in each country, there is less likelihood
of erroneous inferences due to trends in misclassification of cause of
death. Because of the consistency of coding for stroke and
CVD in the eighth and ninth revisions of the ICD, it was assumed that
comparability across these revisions is reasonably good. The use of
seventh revision rubrics was limited to Poland from 1968 to 1969.
Therefore, no comparability adjustments were made to mortality rates
across ICD revisions in this study. The abrupt mortality rate declines
observed in the early 1980s in Poland appear to be contemporaneous with
the implementation of the eighth revision of the ICD in that country.
In general, however, the influence of ICD revisions on mortality rates
appears to be minor, supportive of the relatively low impact of coding
changes on the broad categories of cause of death used in this
study.
In conclusion, stroke mortality rate trends in the US and in Poland
from 1968 to 1994 have been opposing. However, a leveling of stroke
mortality rates during the 1990s may be occurring in the US and for
women and elderly men in Poland. Middle-aged Polish men have shown a
distinctly different mortality rate trend pattern characterized by
increasing stroke, CVD, and non-CVD mortality rates. This suggests that
mortality rates for this group may be the result of fundamentally
different susceptibilities and determinants compared with other groups
in Poland or in the US. Indeed, this group may warrant intensified
research and targeted public health interventions. The observed
national, gender, and ethnic inequalities in stroke mortality are
consistent with differential exposures to avoidable CVD risk
factors, and, although more complex, socioeconomic and community
socioenvironmental factors may also play an important role. These
relative national and ethnic trends occurring in just one generation
suggest major effects of lifestyle, socioenvironmental, and/or medical
care determinants for cross-population differences in stroke mortality
rates.
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Selected Abbreviations and Acronyms
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| CHD |
= |
coronary heart disease |
| CVD |
= |
cardiovascular disease |
| ICD |
= |
International Classification of Diseases |
| MONICA |
= |
Monitoring of Trends and Determinants in Cardiovascular
Disease |
| US |
= |
United States |
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Acknowledgments
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This study was supported by a Polish governmental grant
(contract 11.6), by the State Committee for Scientific Research
(contracts 0253/S4/92, 0380/P05/95, 4–1474-9101, and 4P0D03608), and
by the National Heart, Lung, and Blood Institute (NHLBI) (contracts
N01-HV-1–2243, N01-HV-1–08112, and N01-HV-59224). Support was also
provided to Dr Massing as a postdoctoral fellow in the
Cardiovascular Disease
Epidemiology Training Program funded by the
National Institutes of Health, NHLBI, and National Research Service
Award (grant 5-T32-HL007055). The US National Center for Health
Statistics Compressed Mortality File was provided by the University of
North Carolina at Chapel Hill Institute for Research in Social Science
with the assistance of Walter R. Davis. The authors gratefully
acknowledge Sandra Irving, Ratna Thomas, and Melissa Hockaday of
the Collaborative Studies Coordinating Center, Chapel Hill, NC, for
their assistance.
Received February 2, 1998;
revision received April 7, 1998;
accepted April 7, 1998.
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Abstract
Introduction
