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LETTER |
Gerdi Weidner is with the Preventive Medicine Research Institute, Sausalito, Calif. Virginia S. Cain is with the Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, Md.
Correspondence: Requests for reprints should be sent to Gerdi Weidner, PhD, Preventive Medicine Research Institute, 900 Bridgeway, Sausalito, CA 94965 (e-mail: gweidner{at}yahoo.com).
We appreciate Landsbergis’s comments on our article. We too have emphasized the roles of binge drinking (see, e.g., Collins, chap 9, and Shkolnikov et al, chap 3, in Weidner et al1) and intake of food low in cardioprotective substances (Bobak, chap 22, and Connor et al, chap 23, in Weidner et al1) as potential contributors to the sharp increase in cardiovascular disease (CVD) in many Eastern European countries. Landsbergis is also correct in noting fluctuations in coronary heart disease (CHD) mortality around the late 1980s and early 1990s.
More recent analyses of trends in the Soviet republics from 1965 to 2000 show a very large increase in the early 1990s (often referred to as the "cardiovascular disease epidemic"), followed by some decline and then another sharp rise between 1998 and 2000.2,3 Unfortunately, only a few investigations have linked mortality trends to changes in behaviors and risk factors. Because trends in CVD mortality are influenced by trends in multiple behaviors, risk factors, and medical care, mortality trends generally do not show consistent relationships with trends in any single causal factor (Waldron, chap 5, in Weidner et al1). For example, sex mortality ratios for CHD in the United States and Italy during certain time periods increased, despite decreasing gender differences in current and recent smoking.4 We concur with Waldron’s conclusion that the decreases in CHD in many Western countries are likely to be due to the combined effects of favorable trends in various health behaviors, traditional risk factors, and medical care.1
Causes for mortality trends in Eastern Europe probably include these and other factors. For example, binge drinking, a factor that has not been considered in previous prospective epidemiological studies, has been implicated in the fluctuations in CVD in the countries of the former Soviet Union since the 1980s5 (also Shkolnikov et al, chap 3, in Weidner et al1). Also, negative health consequences of the post-Soviet transition period were most pronounced in countries with the largest increases in income inequality6 (and see Hertzman et al, chap 1, in Weidner et al1). Promising candidates for further investigation also include psychosocial factors (Knox et al, chap 10, and Kristenson and Kucinskiene, chap 25, in Weidner et al1) and gendered responses to stress and coping7 (also Miller and Wortman, chap 19; Solomon, chap 20; and Waldron, chap 5, in Weidner et al1).
Finally, the fact that the transition in Eastern Europe continues to have the strongest negative impact on adult health suggests that current international development policies may have to be expanded to include targets relevant to adult (particularly male) mortality in transition countries.8
References
1. Weidner G, Kopp MS, Kristenson M, eds. Heart Disease: Environment, Stress and Gender. Amsterdam, Netherlands: IOS Press; 2002. NATO Science Series: Life and Behavioural Sciences, vol 327.
2. Andreev EM, Nolte E, Shkolnikov VM, Varavikova E, McKee M. The evolving pattern of avoidable mortality in Russia. Int J Epidemiol. 2003;32:437–446.
3. Notzon FC, Komarov YM, Ermakov SP, et al. Russian Federation and United States, selected years 1985–2000 with an overview of Russian mortality in the 1990s. Vital Health Stat 5. 2003;No. 11.
4. Waldron I. Contributions of biological and behavioural factors to changing sex differences in ischemic heart disease mortality. In: Lopez A, Caselli G, Valkonen T, eds. Adult Mortality in Developed Countries: From Description to Explanation. New York, NY: Oxford University Press; 1995:161–178.
5. McKee M, Shkolnikov V, Leon DA. Alcohol is implicated in the fluctuations in cardiovascular disease in Russia since the 1980s. Ann Epidemiol.2001;11:1–6.[ISI][Medline]
6. Weidner G. Life expectancy in Eastern Europe [letter]. Science. 2000;290:52–53.
7. Williams DR. The health of men: structured inequalities and opportunities. Am J Public Health. 2003;93:724–731.
8. Lock K, Andreev EM, Shkolnikov VM, McKee M. What targets for international development policies are appropriate for improving health in Russia? Health Policy Plann. 2002;17:257–263.
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