Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991

BMJ 1998;316:1047-1051 ( 4 April )

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Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991

Witold A Zatonski, professor, ^a Anthony J McMichael, professor, ^b John W Powles, lecturer. ^c

^a Department of Epidemiology and Cancer Prevention, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 02-781 Warsaw, Poland, ^b Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, London WC1E 7HT, ^c Institute of Public Health, Cambridge CB2 2SR

Correspondence to: Professor Zatonski zatonskiw{at}coi.waw.pl

Objective: To investigate the reasons for the decline in deaths attributed to ischaemic heart disease in Poland since1991 after two decades of rising rates.
Design: Recent changes in mortality were measured as percentage deviations in 1994 from rates predicted by extrapolationof sex and age specific death rates for 1980-91 for diseases ofthe circulatory system and selected other categories. Availabledata on national and household food availability, alcohol consumption,cigarette smoking, socioeconomic indices, and medical servicesover time were reviewed.
Main outcome measures: Age specific and age standardised rates of death attributed to ischaemic heart disease and relatedcauses.
Results: The change in trend in mortality attributed to diseases of the circulatory system was similar in men and womenand most marked (>20%) in early middle age. For ages 45 to 64the decrease was greatest for deaths attributed to ischaemic heartdisease and atherosclerosis (around 25%) and less for stroke (<10%).For most of the potentially explanatory variables considered,there were no corresponding changes in trend. However, between1986-90 and 1994 there was a marked switch from animal fats (estimatedavailability down 23%) to vegetable fats (up 48%) and increasedimports of fruit.
Conclusion: Reporting biases are unlikely to have exaggerated the true fall in ischaemic heart disease; neither isit likely to be mainly due to changes in smoking, drinking, stress,or medical care. Changes in type of dietary fat and increasedsupplies of fresh fruit and vegetables seem to be the best candidates.

Key messages

Among former socialist countries Poland has undergone unusually rapid social and economic changes since 1988-9, including aspects of diet
Mortality from heart disease declined sharply during 1991-4 after long term increases; mortality from stroke declined less strongly
This study investigated what has changed in Poland to reduce the risks of fatal events in people with established ischaemic heart disease
Candidate dietary explanations were the substitution of unsaturated for saturated fats and increased consumption of fresh fruit and vegetables

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