BMJ 2001;323:541-545 ( 8 September )

Papers

Sex matters: secular and geographical trends in sex differences in coronary heart disease mortality

D A Lawlor, lecturer in epidemiology and public health medicine,  S Ebrahim, professor in epidemiology of ageing,  G Davey Smith, professor of clinical epidemiology. 

Department of Social Medicine, University of Bristol, Bristol BS8 2PR

Correspondence to: D A Lawlor D.A.Lawlor{at}bristol.ac.uk

Objective: To examine secular trends and geographical variations in sex differences in mortality from coronary heart disease and investigate how these relate to distributions in risk factors.
Design: National and international data were used to examine secular trends and geographical variations in sex differences in mortality from coronary heart disease and risk factors.
Setting: England and Wales, 1921-98; Australia, France, Japan, Sweden, and the United States, 1947-97; 50 countries, 1992-6.
Data sources: Office for National Statistics, World Health Organization, and Food and Agriculture Organization of the United Nations.
Results: The 20th century epidemic of coronary heart disease affected only men in most industrialised countries and had a very rapid onset in England and Wales, which has been examined in detail. If this male only epidemic had not occurred there would have been 1.2 million fewer deaths from coronary heart disease in men in England and Wales over the past 50 years. Secular trends in mean per capita fat consumption show a similar pattern to secular trends in coronary heart disease mortality in men. Fat consumption is positively correlated with coronary heart disease mortality in men (rs=0.79; 95% confidence interval 0.70 to 0.86) and inversely associated with coronary heart disease mortality in women (-0.30; -0.49 to -0.08) over this time. Although sex ratios for mortality from coronary heart disease show a clear period effect, those for lung cancer show a cohort effect. Sex ratios for stroke mortality were constant and close to unity for the entire period. Geographical variations in the sex ratio for coronary heart disease were associated with mean per capita fat consumption (0.64; 0.44 to 0.78) but were not associated with the sex ratio for smoking.
Conclusion: Sex differences are largely the result of environmental factors and hence not inevitable. Understanding the factors that determine sex differences has important implications for public health, particularly for countries and parts of countries where the death rates for coronary heart disease are currently increasing.


What is already known on this topic
Mortality for coronary heart disease is greater in men than women in most industrialised countries

The most widely accepted explanation for this difference is that women are protected by oestrogen

What this study adds
The sex difference in mortality from coronary heart disease varies over time and between countries in a way that cannot be explained by endogenous oestrogen

These trends indicate that sex differences in mortality from coronary heart disease are driven primarily by environmental factors

Sex differences in coronary heart disease are not inevitable

Understanding more about the factors that cause the sex differences in mortality from coronary heart disease has important public health implications



© BMJ 2001
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

Trends in sex differences in mortality from heart disease
D A Lawlor, S Ebrahim, G Davey Smith, Tessa M Pollard, Colin Fischbacher, and Nigel Unwin
BMJ 2002 324: 237. [Extract] [Full Text]

Grabbed
BMJ 2001 323: 0. [Full Text] [PDF]

Grabbed
BMJ 2001 323: 0. [Full Text] [PDF]

Environmental factors influence sex differences in coronary heart disease mortality
BMJ 2001 323: 0. [Full Text]

This article has been cited by other articles:

  • Hoglund, A T, Tyden, T, Hannerfors, A K, Larsson, M (2009). Knowledge of human papillomavirus and attitudes to vaccination among Swedish high school students. Int J STD AIDS 20: 102-107 [Abstract] [Full text]  
  • Rosengren, A., Perk, J., Dallongeville, J. (2009). CHAPTER 12 Prevention of Cardiovascular Disease. ESC Textbook of Cardiovascular Medicine 2: med-9780199566990-chapter-med-9780199566990-chapter [Abstract] [Full text]  
  • Anand, S. S., Islam, S., Rosengren, A., Franzosi, M. G., Steyn, K., Yusufali, A. H., Keltai, M., Diaz, R., Rangarajan, S., Yusuf, S., on behalf of the INTERHEART Investigators, (2008). Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. Eur Heart J 29: 932-940 [Abstract] [Full text]  
  • Hui, L. L., Schooling, C. M., Leung, S. S. L., Mak, K. H., Ho, L. M., Lam, T. H., Leung, G. M. (2008). Birth Weight, Infant Growth, and Childhood Body Mass Index: Hong Kong's Children of 1997 Birth Cohort. Arch Pediatr Adolesc Med 162: 212-218 [Abstract] [Full text]  
  • Schooling, C. M., Jiang, C. Q., Lam, T. H., Zhang, W. S., Cheng, K. K., Leung, G. M. (2008). Life-Course Origins of Social Inequalities in Metabolic Risk in the Population of a Developing Country. Am J Epidemiol 167: 419-428 [Abstract] [Full text]  
  • Hunt, K., Lewars, H., Emslie, C., Batty, G. D. (2007). Decreased risk of death from coronary heart disease amongst men with higher 'femininity' scores: a general population cohort study. Int J Epidemiol 36: 612-620 [Abstract] [Full text]  
  • Jiang, C., Thomas, G N., Lam, T. H., Schooling, C M., Zhang, W., Lao, X., Adab, P., Liu, B., Leung, G. M, Cheng, K. K. (2006). Cohort Profile: The Guangzhou Biobank Cohort Study, a Guangzhou-Hong Kong-Birmingham collaboration. Int J Epidemiol 35: 844-852 [Full text]  
  • Schooling, M., Leung, G. M, Janus, E. D, Ho, S. Y., Hedley, A. J, Lam, T. H. (2004). Childhood migration and cardiovascular risk. Int J Epidemiol 33: 1219-1226 [Abstract] [Full text]  
  • Lawlor, D. A, Ebrahim, S., Whincup, P., Sterne, J., Papacosta, O., Wannamethee, G., Dhanjil, S., Griffin, M., Nicolaides, A. N, Davey Smith, G. (2004). Sex differences in body fat distribution and carotid intima media thickness: cross sectional survey using data from the British regional heart study. J. Epidemiol. Community Health 58: 700-704 [Abstract] [Full text]  
  • Lawlor, D. A, Davey Smith, G., Ebrahim, S. (2004). Commentary: The hormone replacement-coronary heart disease conundrum: is this the death of observational epidemiology?. Int J Epidemiol 33: 464-467 [Full text]  
  • Khang, Y.-H., Lynch, J. W, Kaplan, G. A (2004). Health inequalities in Korea: age- and sex-specific educational differences in the 10 leading causes of death. Int J Epidemiol 33: 299-308 [Abstract] [Full text]  
  • Brindle, P., Emberson, J., Lampe, F., Walker, M., Whincup, P., Fahey, T., Ebrahim, S. (2003). Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study. BMJ 327: 1267- [Abstract] [Full text]  
  • Chang, W.-C., Kaul, P., Westerhout, C. M., Graham, M. M., Fu, Y., Chowdhury, T., Armstrong, P. W. (2003). Impact of Sex on Long-term Mortality From Acute Myocardial Infarction vs Unstable Angina. Arch Intern Med 163: 2476-2484 [Abstract] [Full text]  
  • Ulmer, H., Kelleher, C., Diem, G., Concin, H. (2003). Long-term tracking of cardiovascular risk factors among men and women in a large population-based health system: The Vorarlberg Health Monitoring & Promotion Programme. Eur Heart J 24: 1004-1013 [Abstract] [Full text]  
  • Lawlor, D. A., Emberson, J. R., Ebrahim, S., Whincup, P. H., Wannamethee, S. G., Walker, M., Smith, G. D. (2003). Is the Association Between Parity and Coronary Heart Disease Due to Biological Effects of Pregnancy or Adverse Lifestyle Risk Factors Associated With Child-Rearing?: Findings From the British Women's Heart and Health Study and the British Regional Heart Study. Circulation 107: 1260-1264 [Abstract] [Full text]  
  • Pinn, V. W. (2003). Sex and Gender Factors in Medical Studies: Implications for Health and Clinical Practice. JAMA 289: 397-400 [Full text]  
  • Lawlor, D. (2002). Hormone Replacement Therapy and Cardiovascular Disease. The Current Status of Research and Practice.: AR Genazzani. London UK, New York USA: The Parthenon Publishing Group, 2001, pp. 188, US$77.95 ISBN: 1 84214 038 8.. Int J Epidemiol 31: 1278-1279 [Full text]  
  • Lawlor, D. A, Ebrahim, S., Davey Smith, G. (2002). Role of endogenous oestrogen in aetiology of coronary heart disease: analysis of age related trends in coronary heart disease and breast cancer in England and Wales and Japan. BMJ 325: 311-312 [Full text]  
  • Fletcher, R. J., Higginbotham, N., Dobson, A. (2002). Men's Perceived Health Needs. J Health Psychol 7: 233-241 [Abstract]  
  • Bolego, C., Poli, A., Paoletti, R. (2002). Smoking and gender. Cardiovasc Res 53: 568-576 [Abstract] [Full text]  
  • Lawlor, D A, Ebrahim, S, Smith, G D., Pollard, T. M, Fischbacher, C., Unwin, N. (2002). Trends in sex differences in mortality from heart disease. BMJ 324: 237-237 [Full text]  

Rapid Responses:

Read all Rapid Responses

Sex differences in coronary heart disease mortality is really complex
Sergio Stagnaro
bmj.com, 10 Sep 2001 [Full text]
Sex matters and gender matters
Judith Lorber
bmj.com, 11 Sep 2001 [Full text]
Oestrogen may contribute to variation in sex differences in coronary heart disease mortality
Tessa M Pollard, et al.
bmj.com, 22 Sep 2001 [Full text]
Sex may well matter, but is it old-fashioned to say so?
Cecily Kelleher
bmj.com, 6 Dec 2001 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ