A cohort study on cerebrovascular disease in middle-aged and elderly population in rural areas in Jiangxi Province, China


Qiu, D.; Mei, J.; Tanihata, T.; Kawaminami, K.; Minowa, M.

Journal of Epidemiology 13(3): 149-156

2003


To clarify the risk factors of CVD deaths in rural areas in Jiangxi Province, China, a cohort study was carried out from September 1, 1994 through December 31, 2000 involving 50,252 participants aged 40 years or older in 4 counties. Among the 3,429 deaths, 671 cases (398 males and 273 females) died of CVD. In addition, excluding 183 cases with a previous history of CVD, 632 CVD deaths out of 50,069 subjects were analyzed using Cox proportional hazard models. The multivariate hazard ratio (HR) for CVD mortality significantly increased in parallel with age, blood pressure and degree of liking for salty foods (p for trend < 0.01). The multivariate HR for CVD mortality of ex-drinkers was 1.55 (95% CI: 1.04, 2.31) compared with non-drinkers. The multivariate HR for CVD mortality of subjects who ate meat once or twice per month was 0.75 (95% CI: 0.62, 0.91) compared with those who never ate meat or seldom. There was no significant relationship between smoking and CVD mortality. Our results indicated that the main risk factors for CVD mortality were advancing age, high-normal blood pressure and hypertension. The risk in these areas was lower in subjects who disliked salty foods and those who ate meat once or twice per month.

Journal
of
Epidemiology
Vol.
13.
No.
3
May
2003
Original
Article
A
Cohort
Study
on
Cerebrovascular
Disease
in
Middle-aged
and
Elderly
Population
in
Rural
Areas
in
Jiangxi
Province,
China
Dongmei
Qiu,'
Jiamo
Mei,
2
Takeo
Tanihata,
3
Katsuhiko
Kawaminami,
3
and
Masumi
Minowa
3
To
clarify
the
risk
factors
of
CVD
deaths
in
rural
areas
in
Jiangxi
Province,
China,
a
cohort
study
was
carried
out
from
September
1,
1994
through
December
31,
2000
involving
50,252
participants
aged
40
years
or
older
in
4
counties.
Among
the
3,429
deaths,
671
cases
(398
males
and
273
females)
died
of
CVD.
In
addition,
excluding
183
cases
with
a
previous
history
of
CVD,
632
CVD
deaths
out
of
50,069
subjects
were
analyzed
using
Cox
proportional
hazard
models.
The
multivariate
hazard
ratio
(HR)
for
CVD
mortality
significantly
increased
in
parallel
with
age,
blood
pressure
and
degree
of
liking
for
salty
foods
(p
for
trend<0.01).
The
multivariate
HR
for
CVD
mortality
of
ex-drinkers
was
1.55
(95°/0CI:
1.04,
2.31)
compared
with
non-drinkers.
The
multivariate
HR
for
CVD
mortality
of
subjects
who
ate
meat
once
or
twice
per
month
was
0.75
(95%CI:
0.62,
0.91)
compared
with
those
who
never
ate
meat
or
sel-
dom.
There
was
no
significant
relationship
between
smoking
and
CVD
mortality.
Our
results
indicated
that
the
main
risk
factors
for
CVD
mortality
were
advancing
age,
high-normal
blood
pressure
and
hyper-
tension.
The
risk
in
these
areas
was
lower
in
subjects
who
disliked
salty
foods
and
those
who
ate
meat
once
or
twice
per
month.
J
Epidemic,'
2003;13:149-156.
Key
words:
cohort
study,
cerebrovascular
disease,
mortality
rate,
hazard
ratio,
rural
area,
China.
Disease
patterns
have
been
showing
a
notable
change
in
China
following
the
rapid
socioeconomic
changes
caused
by
economic
reforms.
Chronic
non-communicable
diseases
have
superseded
communicable
diseases
as
the
principal
cause
of
death
in
China.'
This
change
has
occurred
not
only
in
urban
areas
but
also
in
rural
areas.
In
both
the
areas,
cerebrovascular
disease
(CVD)
has
become
the
second
largest
cause
of
death
in
China.
The
mortality
of
CVD
increased
from
39.1/100,000
in
1957
to
149.5/100,000
in
1998
(according
to
data
of
the
Ministry
of
Health,
People's
Republic
of
China).
Moreover,
it
increased
more
rapidly
in
rural
areas
than
in
urban
areas.'
It
is
reported
that
more
than
1
million
people
die
of
CVD
in
a
year
in
China.'
The
high
mortality
and
high
disability
rates
of
CVD
have
not
only
affected
the
health
and
quality
of
life
of
the
victims,
but
also
caused
heavy
economic
and
mental
burdens
for
families
and
the
country.
Furthermore,
the
burden
of
CVD
is
likely
to
increase
substantially
in
the
future
because
of
the
aging
population
and
the
changing
of
lifestyles.
Thus,
it
is
necessary
to
take
effective
measures
against
CVD
as
soon
as
possible.
Until
now
there
have
been
no
sufficient
epi-
demiologic
studies
carried
out
in
rural
areas
in
China."
The
pre-
sent
study
was
conducted
to
explore
the
risk
factors
associated
with
CVD
deaths
in
the
rural
areas
in
Jiangxi
Province,
China.
We
hope
that
our
results
may
provide
public
health
information
on
the
prevention
and
management
of
CVD,
as
well
as
sugges-
tions
for
relieving
the
burden
caused
by
CVD.
METHODS
The
investigation
was
performed
with
persons
who
were
40
years
or
older
who
lived
in
the
study
areas,
Sixi,
Lixi,
Luoping,
Putian,
Luxi,
Shinao,
Meizhuang,
and
Ertang
Townships
in
Shanggao,
Wuning,
Jinxian,
and
Gaoan
Counties
in
Jiangxi
Province,
China.
Inpatients
were
excluded
from
the
study.
Jiangxi
Province,
with
a
total
population
of
about
42
million,
is
located
in
the
middle
southwest
of
China,
along
the
middle
lower
reaches
of
the
Yangtze
River.
Among
the
population
in
the
province,
Received
August
5,
2002,
and
accepted
December
18,
2002.
'
Department
of
Epidemiology
and
Environmental
Health,
Juntendo
University
School
of
Medicine.
Jiangxi
Center
for
Disease
Control
and
Prevention.
'
Department
of
Epidemiology,
National
Institute
of
Public
Health.
Address
for
correspondence:
Dongmei
Qiu,
Department
of
Epidemiology
and
Environmental
Health,
Juntendo
University
School
of
Medicine,
2-1-1,
Hongo,
Bunkyo-ku
Tokyo,
113-8421,
Japan.
149
150
Cerebrovascular
Disease
in
China
approximately
60%
are
farmers,
25%
work
in
industries,
such
as
excavation
and
manufacturing,
and
15%
are
others
(Jiangxi
CDC,
personal
communication).
In
the
investigating
areas,
more
than
90%
are
farmers,
and
rice
is
the
main
crop.
In
1993,
the
birth
rate
and
mortality
rate
in
this
province
were
20.3%o
and
6.9%0,
respec-
tively,
while
the
birth
rate
and
mortality
rate
in
the
whole
country
were
18.1%0
and
6.6%o,
respectively.
Average
rural
household
per
capita
net
income
in
Jiangxi
Province
is
i
the
middle
of
31
metropolises
and
provinces
in
China.'
The
climate
in
the
province
is
relatively
warm
and
moist;
the
average
temperature
is
16.3t
—19.5t
and
the
annual
precipitation
of
rainfall
is
1,351-1,934
mm.
6
Between
September
1,
1994
and
June
30,
1996,
a
door-to-door
baseline
survey
about
lifestyle
and
health
status
was
performed
with
50,252
subjects
(93.3%
of
eligible
subjects)
by
an
investigat-
ing
team
using
a
structured
questionnaire.
The
institutions
involved
in
the
survey,
ranging
from
basic
to
high
level
facilities
included
village
clinics,
township
and
county
hospitals,
Centers
for
Disease
Control
and
Prevention
(CDC)
from
county
to
provincial
level.
Physicians
who
belonged
to
county
CDC
or
lower
levels
were
trained
by
those
of
Jiangxi
CDC
for
one
week
before
conducting
the
baseline
survey.
About
the
300
physicians
participated
in
this
survey.
All
the
interviews
were
supervised
by
the
physicians
from
the
Jiangxi
CDC,
and
they
were
also
responsible
for
checking
the
finished
question-
naires.
The
surveyed
items
were
sex,
age,
frequency
of
food
intake
(meat,
egg,
fresh
fish,
Chinese
pickles,
tofu,
green-yellow
vegeta-
bles,
light-colored
vegetables,
milk,
confectionery,
and
fruit),
lik-
ing
for
fatty
foods
and
salty
foods,
cigarette
smoking,
alcohol
drinking,
occupation,
living
environment,
life
situation,
and
past
histories
of
CVD,
heart
disease,
hypertension
and
malignant
neo-
plasm.
Concerning
the
diseases,
in
addition
to
confirmation
by
the
medical
records
preserved
by
the
subjects
themselves,
they
were
also
diagnosed
by
the
medical
examinations
made
by
physicians
of
the
county
and
township
hospitals
in
the
subjects'
homes.
Further
clinical
examinations
were
carried
out
in
the
township
hospitals
or
the
county
hospitals
if
necessary.
Other
information
collected
at
the
baseline
survey
included
the
measurement
of
height,
weight,
and
blood
pressure.
According
to
the criteria
of
China,'
body
mass
index
(BMI)
was
classified
into
three
groups
as;
BMI<18.5,
18.5
BMI
23.9
and
24.0.
The
value
of
the
blood
pressure
was
the
mean
of
3
time
measurements.
When
systolic
blood
pressure
(SBP)<130
mmHg
and
diastolic
blood
pressure
(DBP)<85
mmHg,
it
was
classified
as
normal;
when
130
SBP
139
mmHg
and/or
855DPBs
89
mmHg,
it
was
classified
as
"high-normal";
when
SBPz
140
mmHg
and/or
DPB
Z
90
mmHg,
it
was
classified
as
hypertension
according
to
the
reference
of
WHO/
ISH.
8
Subjects
who
had
histories
of
hyper-
tension
were
regarded
as
cases
of
hypertension.
As
of
December
31,
2000,
among
the
50,252
cohort
subjects,
only
225
subjects
had
moved
away
from
the
investigating
areas
(and
therefore
had
been
lost
to
follow-up). Regarding
mortality
data,
follow-up
was
essentially
complete
(follow-up
rate
was
99.6%).
A
follow-up
survey
(including
date
of
death
and
causes
of
death)
of
the
subjects
was
monitored
regularly
by
means
of
a
fol-
low-up
report.
Village
physicians
who
lived
in
the
same
village
as
cohort
subjects
filled
out
follow-up
reports
and
submitted
them
to
the
township
hospitals
every
10
days.
After
receiving
a
follow-up
report,
a
physician
from
the
township
hospital
immediately
visit-
ed
the
home
of
the
dead
person,
and
after
the
township
hospital
physician
confirmed
the
diagnosis,
he
or
she
submitted
a
report
to
the
county
CDC
once
per
month.
A
physician
from
the
county
CDC
visited
the
home
of
any
dead
person
who
could
not
be
con-
firmed
by
the
township
hospital.
The
county
CDC
submitted
the
reports
to
the
Jiangxi
CDC
quarterly
during
the
year.
We
obtained
the
data
from
the
Jiangxi
CDC
annually.
Causes
of
death
were
determined
mainly
from
death
certificates,
supplemented
if
neces-
sary,
by
medical
records
and
by
asking
family
members
or
the
vil-
lage
physicians.
Survivors
and
subjects
who
had
moved
away
from
the
investigating
areas
were
confirmed
by
using
registration
of
residents
in
local
police
stations
annually.
The
investigating
team
not
only
explained
the
purpose,
meth-
ods,
procedure,
the
meaning
and
advantage
of
this
survey,
but
also
emphasized
voluntary
nature
of
participation
in
the
survey
to
the
residents
before
interview.
All
the
interviews
were
performed
only
with
residents
who
were
willing
to
participate
in
this
study.
Each
subject
accumulated
follow-up
time
beginning
at
the
baseline
and
ending
at
the
date
of
death
or
other
relevant
endpoint
(death
from
causes
other
than
CVD,
or
December
31,
2000,
whichever
came
first).
In
the
death
cases,
causes
of
deaths
were
coded
according
to
the
basic
tabulation
list
of
the
International
Classification
of
Diseases,
Ninth
Revision
(ICD-9).
The
specific
endpoints
of
this
study
were
deaths
from
CVD
(ICD-9:29),
which
were
cerebral
hemorrhage
(ICD-9:
291),
cerebral
infarction
(ICD-
9:
292),
subarachnoid
hemorrhage
(ICD-9:
290)
and
other
CVD
which
could
not
be
clearly
diagnosed
(ICD-9:
293-294).
We
selected
confounding
factors
on
the
principle
of
p
<
0.20
according
to
Wald's
test
and
took
into
account
the
importance
of
variables.
We
used
Cox
proportional
hazards
models
to
estimate
the
risk
of
mortality
(cumulative
mortality)
by
CVD,
adjusting
for
sex,
age
and
other
covariates.
Selected
confounders
were
sex
(males
and
females),
age
group
(40-49,
50-59,
60-69,
70-79,
and
80+
years),
area
(Wuning
county,
Shanggao
county,
Jinxian
coun-
ty,
and
Gaoan
county),
cigarette
smoking
status
(non-smoker,
ex-
smoker,
and
current
smoker),
alcohol
drinking
status
(non-
drinker,
ex-drinker,
and
current
drinker),
blood
pressure
(normal,
high-normal,
and
hypertension),
BMI
(<18.5,
18.5-23.9,
and
24.0
kg/m
2
),
marital
status
(married,
never
married,
divorced,
and
widowed),
fatty
foods
(dislike,
normal,
and
like),
salty
foods
(dis-
like,
normal,
and
like),
frequency
of
Chinese
pickles
intake
(never
or
seldom,
once
or
twice
per
month,
and
more
than
once
per
week),
frequency
of
meat
intake
(never
or
seldom,
once
or
twice
per
month,
and
more
than
once
per
week),
sleeping
hours
per
day
(6
hours
or
less,
7
to
8
hours
per
day,
and
9
hours
or
more).
The
Qui
D,
et
al.
151
95%
confidence
interval
(CI)
was
calculated
for
each
hazard
ratio
(HR).
We
excluded
183
cases
who
had
suffered
from
CVD
before
the
baseline
date
when
analyzing
the
causes
of
death
by
CVD.
Statistical
testing
for
p
for
trend
of
CVD
mortality
associated
with
various
variables
was
based
on
ordinal
categories
using
Cox
pro-
portional
hazard
models.
Data
were
analyzed
with
SPSS®10.0
for
Windows.
RESULTS
For
50,252
subjects
(25,338
males
and
24,914
females),
the
mean
age
was
55.3
years
old.
The
number
of
current
smokers
was
far
greater
than
that
of
ex-smokers.
A
similar
difference
was
observed
in
regard
to
current
drinkers
and
ex-drinkers.
The
preva-
lence
of
hypertension
was
20.4%.
Mean
BMI
was
20.1
kg/m
2
(For
details,
see
Table
1).
By
December
31,
2000,
except
for
183
cases
that
had
a
history
of
CVD,
50,069
cohort
participants
(25,226
males
and
24,843
females)
had
contributed
257,568
person-years
of
follow-up.
During
about
6
years
of
follow-up,
3,358
(2,018
males
and
1,340
females)
deaths
occurred,
46,486
(23,074
males
and
23,
412
females)
persons
survived,
and
225
(134
males
and
91
females)
persons
had
moved
(Table
2).
Among
the
3,358
deaths,
632
(377
males
and
255
females)
cases
died
of
CVD,
of
which
432
and
76
were
cerebral
hemorrhage
and
cerebral
infarction,
respectively
(Table
3).
Table
1.
Distributions
of
selected
characteristics
of
cohort
participants
at
baseline,
Jiangxi
Province,
China,
between
1994
and
1996.
Males
Females
Total
No.
of
subjects
Age
group
(%)
25338
24914
50252
40-49
years
41.6
40.6
41.1
50-59
24.4
21.6
23.0
60-69
20.6
20.9
20.8
70-79
11.3
13.3
12.3
80+
2.1
3.5
2.8
Mean
age
(years)
±
SD
54.8
±11.4
55.8
±
12.2
55.3
±11.8
Area
(%)
Wuning
40.7
38.6
39.7
Shanggao
19.9
19.5
19.7
Gaoan
18.6
20.5
19.6
Jinxian
20.7
21.4
21.0
Cigarette
smoking
status
(%)
Non-smoker
21.5
93.4
57.1
Ex-smoker
5.4
0.6
3.0
Current
smoker
73.1
6.1
39.9
Alcohol
drinking
status
(%)
Non-
drinker
36.7
78.1
57.2
Ex-drinker
2.6
1.4
2.0
Current
drinker
60.6
20.5
40.8
Blood
pressure
*
(%)
Normal
"
62.9
66.7
64.8
High-normal
"
16.7
13.0
14.8
Hypertension
""
20.4
20.3
20.4
Mean
body
mass
index
(kg/m
2
)
±
SD**
20.3
±
2.3
20.0±
2.7
20.1
±
2.5
*
Categories
followed
the
criteria
of
WHO.
SBP:
systolic
blood
pressure
(mmHg);
DBP:
diastolic
blood
pressure
(mmHg).
"
Normal
(SBP<130
and
DBP<85).
"
High-normal
(130_
SBP_
139
and/or
85
DBP
89).
""
Hypertension
(SBP.
140
and/or
DBP
90
and
those
who
had
histories
of
hypertension).
**
SD:
Standard
deviation.
152
Cerebrovascular
Disease
in
China
Table
2.
Distributions
of
followed-up
results
(%)
(from
September
1994*
through
December
2000).
Males
Females
Total
Died
2018
(
8.0)
1340
(
5.4)
3358
(
6.7)
Survived
23074
(
91.5)
23412
(
94.2)
46486
(
92.8)
Removed
134
(
0.5)
91
(
0.4)
225
(
0.4)
Total
25226
(100.0)
24843
(100.0)
50069
(100.0)
*
The
entry
date
for
each
investigated
area
was
different
from
1994
to
1996.
Note:
The
cases
who
had
a
history
of
cerebrovascular
disease
were
excluded.
Table
3.
Number
of
deaths
by
cerebrovascular
disease
and
other
diseases
*
(%).
Males
Females
Total
Cerebrovascular
disease
*
377
(
18.7)
255
(
19.0)
632
(
18.8)
Cerebral
hemorrhage
**
257
(
12.7)
175
(
13.1)
432
(
12.9)
Cerebral
infarction
"
45
(
2.2)
31
(
2.3)
76
(
2.3)
Subarachnoid
hemorrhage
"
22
(
1.1)
12
(
0.9)
34
(
1.0)
Uncertain
cerebrovascular
diseases
type
53
(
2.6)
37
(
2.8)
90
(
2.7)
Other
causes
1641
(
81.3)
1085
(
81.0)
2726
(
81.2)
Total
2018
(100.0)
1340
(100.0)
3358
(100.0)
*
The
category
of
the
basic
tabulation
list
of
ICD-9
(International
Classification
of
Diseases,
Ninth
Revision)
is
29.
**
The
subcategory
is
291.
"
The
subcategory
is
292.
"
The
subcategory
is
290.
$
The
subcategories
are
293-294.
Note:
The
cases
who
had
a
history
of
cerebrovascular
disease
were
excluded.
As
shown
in
Table
4,
the
HR
of
CVD
mortality
rate
increased
rapidly
with
advancing
age
(p
for
trend
<
0.01).
Adjustment
for
sex,
area
and
other
covariates
listed
in
Table
4
did
not
affect
the
positive
increase
tendency
(p
for
trend<0.01).
The
HRs
and
multi-
variate
HRs
of
CVD
mortality
rates
approximately
doubled
every
10
years
from
the
40-49
age
groups
to
80+
age
groups.
The
HR
of
CVD
mortality
rate
increased
about
29-fold
when
the
oldest
group
(80+
age
group)
and
the
40-49
age
groups
were
compared.
The
multivariate
HR
of
CVD
mortalities
rate
in
the
80+
age
group
was
19.85
compared
with
the
40-49
age
group.
When
compared
with
non-drinkers,
ex-drinkers
showed
a
69%
significant
increase
in
HR
of
CVD
mortality
rate.
The
significant
increase
was
also
shown
in
the
multivariate
analysis
(HR=1.55).
The
HR
of
CVD
mortality
rate
for
current
drinkers
showed
a
bor-
derline
significant
increase
when
compared
with
non-drinkers
(HR=1.18).
However,
in
the
multivariate
analysis,
this
increase
was
not
significant.
The
tendency
of
risk
for
CVD
mortality
rate
significantly
increased
with
blood
pressure
(p
for
trend
<
0.01).
A
similar
trend
was
observed
in
regard
to
the
multivariate
HR
(p
for
trend
<
0.01).
Compared
with
subjects
with
normal
blood
pressure,
the
HRs
for
those
with
high-normal
blood
pressure
and
those
with
hypertension
were
1.40
and
2.12,
respectively.
Compared
with
subjects
with
normal
blood
pressure,
the
multivariate
HRs
for
those
with
high-normal
blood
pressure
and
those
with
hyperten-
sion
were
1.38
and
2.06,
respectively.
The
HR
of
CVD
mortality
rate
showed
a
significant
increasing
tendency
associated
with
degree
of
liking
for
salty
foods
(p
for
trend
<
0.01).
According
to
multivariate
analysis,
a
significant
increasing
tendency
was
also
observed
(p
for
trend<0.01).
Compared
with
subjects
who
disliked
salty
foods,
the
HRs
of
CVD
mortality
rates
for
those
who
had
normal
feelings
about
salty
foods
and
those
who
liked
salty
foods
were
1.41
and
1.53,
respectively.
The
multivariate
HRs
of
CVD
mortality
rates
for
subjects
who
had
normal
feelings
about
salty
foods
and
those
who
liked
salty
foods
were
1.40
and
1.46,
respectively,
compared
with
subjects
who
disliked
salty
foods.
There
was
no
significant
asso-
ciation
between
Chinese
pickles
(salty
foods)
intake
and
CVD
mortality
rate
in
the
univariate
analysis.
However,
the
HR
of
CVD
mortality
rate
showed
a
significant
reducing
tendency
with
increasing
frequency
of
Chinese
pickles
intake
in
multivariate
analysis
(p
for
trend
=
0.03).
Compared
with
subjects
who
never
ate
Chinese
pickles
or
ate
them
seldom,
the
HR
of
CVD
mortality
rate
for
those
who
ate
Chinese
pickles
more
than
once
per
week
Qui
D,
et
al.
153
Table
4.
Hazard
ratios
of
cerebrovascular
disease
mortality.*
Person-years
No.
of
deaths
HR'
95%CI
**
Multivariate
HR
H
95%CI
**
(Age
group)
40-49
years
108556
59
1.00
1.00
50-59
60-69
70-79
60423
53203
29444
77
177
234
2.32
6.18
15.16
(
1.65
-
3.26)
(
4.61
-
8.30)
(11.39
-
20.17)
2.14
5.13
11.38
(
1.52
-
3.01)
(
3.79
-
6.94)
(
8.34
-
15.54)
80+
5942
85
28.78
(20.63
-
40.16)
19.85
(13.65
-
28.87)
p
for
trend
<0.01
<0.01
(Cigarette
smoking
status)
Non-smoker
146469
320
1.00
1.00
Ex-smoker
7034
43
1.52
(
1.08
-
2.15)
1.40
(
0.98
-
2.00)
Current
smoker
102939
264
1.12
(
0.90
-
1.38)
1.08
(
0.87
-
1.34)
p
for
trend
0.41
0.59
(Alcohol
drinking
status)
Non-
drinker
147088
341
1.00
1.00
Ex-drinker
4768
28
1.69
(
1.14
-
2.49)
1.55
(
1.04
-
2.31)
Current
drinker
105529
261
1.18
(
0.99
-
1.40)
1.12
(
0.93
-
1.34)
p
for
trend
0.06
0.23
(Blood
pressure)'
Normal
'
169071
239
1.00
1.00
High-normal
"
37862
102
1.40
(
1.11
-
1.77)
1.38
(
1.09
-
1.74)
Hypertension
'"
50636
291
2.12
(
1.78
-
2.54)
2.06
(
1.72
-
2.47)
p
for
trend
<0.01
<0.01
(Body
mass
index)
'
<18.5
64355
222
1.00
1.00
18.5-23.9
177928
385
1.13
(
0.95
-
1.34)
1.12
(
0.94
-
1.33)
.24.0
15285
25
1.14
(
0.75
-
1.73)
1.03
(
0.68
-
1.58)
p
for
trend
0.18
0.33
(Marital
status)
Married
214233
399
1.00
1.00
Never
married
2870
7
1.23
(
0.58
-
2.61)
1.25
(
0.59
-
2.65)
Divorced
2617
6
1.01
(
0.45
-
2.26)
0.95
(
0.42
-
2.13)
Widowed
p
for
trend
37849
220
1.22
(
1.01
-
1.47)
1.16
(
0.96
-
1.41)
(Fatty
foods)
Dislike
6401
14
1.00
1.00
Normal
93626
241
1.28
(
0.75
-
2.20)
1.24
(
0.72
-
2.15)
Like
157542
377
1.37
(
0.80
-
2.33)
1.33
(
0.78
-
2.29)
p
for
trend
0.23
0.23
(Salty
foods)
Dislike
60659
112
1.00
1.00
Normal
165613
433
1.41
(
1.15
-
1.74)
1.40
(
1.13
-
1.73)
Like
31296
87
1.53
(
1.15
-
2.02)
1.46
(
1.10
-
1.95)
p
for
trend
<0.01
<0.01
(Frequency
of
Chinese
pickles
intake)
Never
or
seldom
159945
412
1.00
1.00
Once
or
twice
per
month
48500
I16
0.92
(
0.75
-
1.13)
0.91
(
0.74
-
1.13)
More
than
once
per
week
49123
104
0.86
(
0.69
-
1.06)
0.79
(
0.63
-
0.98)
p
for
trend
0.14
0.03
(Frequency
of
meat
intake)
Never
or
seldom
52002
165
1.00
1.00
Once
or
twice
per
month
142481
322
0.77
(
0.64
-
0.93)
0.75
(
0.62
-
0.91)
More
than
once
per
week
63085
145
0.83
(
0.66
-
1.04)
0.84
(
0.66
-
1.06)
p
for
trend
0.10
0.13
Sleeping
hours
per
day
6
hours
or
less
21465
97
1.00
1.00
7
to
8
hours
180847
376
0.78
(
0.62
-
0.98)
0.86
(
0.68
-
1.09)
9
hours
or
more
55257
159
0.96
(
0.74
-
1.23)
1.01
(
0.78
-
1.31)
p
for
trend
0.81
0.65
Missing
values
and
the
cases
who
had
a
history
of
cerebrovascular
disease
were
excluded.
HR,
hazard
ratio
adjusted
for
sex
and
category
of
age
(40-49,
50-59,
60-69,
70-79,
and
80+
years).
If
Multivariate
HR.
hazard
ratio
adjusted
for
sex,
different
areas
(Wuning,
Shanggao,
Gaoan
and
Jinxian
County)
and
the
factors
listed
in
this
table.
CI,
confidence
interval.
Category
was
according
to
criterion
of
WHO.
SBP:
systolic
blood
pressure
(mmHg);
DBP:
diastolic
blood
pressure
(mmHg).
Normal
(SBP<130
and
DBP<85).
High-normal
(130
SBP139
and/or
85
_DBP89).
Hypertension
(SBP?
140
and/or
DBP
90
and
those
who
had
histories
of
hypertension).
154
Cerebrovascular
Disease
in
China
was
less
than
unity.
The
HR
of
CVD
mortality
rate
decreased
in
subjects
who
ate
meat
(including
chicken,
pork,
and
beef)
once
or
twice
per
month
and
those
who
ate
meat
more
than
once
per
week
(subjects
who
never
ate
meat
or
ate
it
seldom
were
the
reference).
The
HR
of
CVD
was
significant
only
in
subjects
who
ate
meat
once
or
twice
per
month
(HR
=0.77).
A
similar
result
was
found
in
using
the
multivariate
analysis
(HR=0.75);
however,
there
was
no
signifi-
cant
association
between
degree
of
liking
for
fatty
foods
and
CVD
mortality
rate.
Furthermore,
no
significant
association
was
found
between
any
category
of
liking
for
fatty
foods
and
CVD
mortality
rate.
Regarding
both
crude
and
adjusted
HRs,
we
found
that
there
was
no
significant
association
between
BMI
and
CVD
mortality
rate.
Although
ex-smokers
showed
a
significant
increase
in
HR
for
CVD
mortality
rate
when
compared
with
non-smokers,
this
significant
increase
was
not
observed
in
the
multivariate
analysis.
Significant
increase
in
HR
for
CVD
mortality
rate
was
observed
in
widowers
(currently
married
subjects
were
reference);
signifi-
cant
decrease
was
observed
in
subjects
who
slept
7
to
8
hours
per
day
(subjects
who
slept
6
hours
or
less
were
reference).
However,
both
of
these
significant
differences
disappeared
in
the
multivari-
ate
analysis.
DISCUSSION
As
shown
in
Table
1,
the
current
smoking
rate
among
males
(73.1%)
in
our
study
was
higher
than
that
in
China
nationwide
(66.8%),
9
and
among
rural
males
in
Beijing
(70.7%);
10
whereas
the
current
smoking
rate
among
females
(6.1%)
was
lower
than
that
in
China
nationwide
(7.4%).
9
Current
alcohol
drinking
rates,
both
among
males
(60.6%)
and
females
(20.5%)
were
higher
in
our
study
than
those
in
China
nationwide
(males:
50.4%,
females:
5.3%).
9
The
high
smoking
rate
and
drinking
rate
suggested
that
this
subject
population
might
be
insufficiently
educated
about
life
style
for
health.
The
prevalence
of
hypertension
among
males
(20.4%)
and
females
(20.3%)
in
our
study
was
lower
than
those
in
rural
areas
in
Beijing
(males:
21.9%,
females:
22.6%;
SBP
160
mmHg
and/or
DBP95
mmHg
and
normotensives
who
had
taken
hypotensive
medicine
within
2
weeks)
respectively.I0
The
mean
BMI
of
males
and
females
in
our
study
(males:
20.3
kg/m
2
;
females:
20.0
kg/m')
were
lower
than
that
in
males
(23.9
kg/m
2
)
and
females
(24.6
kg/m')
in
rural
areas
in
Beijing,
respectively.ifi
These
low
prevalences
of
hypertension
and
mean
BMI
may
be
partly
explained
by
insufficient
nutrition
(for
example,
low
ani-
mal
protein)
due
to
low
economic
state.
Based
on
Table
2
and
Table
3,
the
age-adjusted
death
rates
(standard
population
was
the
1990
Population
Census
of
China,
by
direct
method)
of
all
cause
and
CVD
death
rate
were
calculated.
The
results
(1,305
for
all
causes
of
death
and
254
for
CVD
deaths
per
100,000
person-
years)
were
lower
than
those
of
the
same
age
population
in
China
(1,347/100,000
and
281/100,000),
respectively."
Using
the
same
standard
population,
we
also
calculated
the
age-adjusted
death
rate
of
CVD
of
the
same
age
population
in
Japan
in
1970,
when
Japanese
CVD
mortality
began
to
decrease.
This
Japanese
age-
adjusted
death
rate
for
CVD
(520/100,000)
12
was
much
higher
than
that
in
our
study.
Therefore,
we
consider
that
CVD
mortality
in
the
investigated
areas
is
likely
to
increase
in
the
future,
follow-
ing
a
similar
increasing
tendency
to
that
of
Japan
before
the
1970s.
When
we
compared
the
classification
for
death
causes
of
CVD
in
our
study
with
that
in
Japan
around
1960s,
we
found
that
more
than
50%
of
deaths
were
cerebral
hemorrhage
among
CVD
deaths
both
in
our
study
(Table
3)
and
in
Japan."
In
analyzing
this
phe-
nomenon,
it
should
be
considered
that
both
in
Japan
in
1960s
(in
Japan,
the
time
for
introduction
of
computerized
tomography
equipment
was
1975'
4
')
and
in
our
study,
a
large
part
of
the
diag-
noses
of
CVD
as
death
cause
were
not
made
by
computerized
tomography,
but
made
according
to
symptoms
and
clinical
exami-
nation
only.
In
the
present
study,
considering
the
above
situation
we
did
not
analyze
cerebral
hemorrhage
and
cerebral
infarction
separately.
As
shown
in
Table
4,
we
found
that
the
risk
of
CVD
mortality
rate
for
middle-aged
and
elderly
population
in
these
areas
showed
a
significant
increasing tendency
with
advancing
age,
increasing
blood
pressure
and
increasing
degree
of
liking
for
salty
foods.
The
risk
in
ex-drinkers
for
CVD
mortality
rate
also
showed
a
sig-
nificant
increase
compared
with
that
of
non-drinkers.
The
risk
for
CVD
mortality
rate
among
subjects
who
ate
meat
once
or
twice
per
month
showed
a
25%
significant
reduction
compared
with
those
who
never
ate
meat
or
ate
it
seldom.
Age
was
the
greatest
risk
factor
for
CVD
mortality.
For
every
successive
10
years
after
age
55,
the
CVD
rate
more
than
doubled
in
both
sexes.'
Compared
with
the
age
45-54
group,
the
mortality
rate
of
CVD
(only
including
cerebral
hemorrhage
and
cerebral
infarction)
in
the
age
65-74
group
increased
19.7
times
in
rural
areas
in
Tianjin.
4
This
kind
of
increasing
trend
was
also
observed
in
a
study
of
urban
communities
in
six
cities
in
China."
Hypertension
was
the
other
important
risk
factor
for
CVD
mor-
tality.
Hypertension
has
been
independently
associated
with
CVD
mortality
worldwide.'"
A
history
of
hypertension
was
also
reported
as
a
primary
risk
factor
of
CVD
among
men
in
Shanghai.'
Elevated
blood
pressure
was
a
firmly
established
risk
factor
for
CVD
mortality:
9
Geographic
gradient
for
mortality
rate
of
CVD
paralleled
the
prevalence
of
hypertension
in
China.'
In
a
15-year
cohort
study
conducted
in
Finland,
according
to
multi-
variate
analysis,
it
was
found
that
the
relative
risk
of
CVD
mortal-
ities
for
people
who
had
hypertension
(SBPz
160mmHg
and
DBP_95mmHg)
were
elevated
3.5-fold
and
4.5-fold,
compared
to
those
who
had
normal
blood
pressure
(SBP<160mmHg
and
DBP<95mmHg)
in
men
and
women.'
In
a
meta-analysis
study
in
China,
hypertensive
patients
had
more
than
5-fold
greater
risk
of
CVD
than
normotensives."
Current
methods
of
treatment
for
hypertension
in
China
are
non-drug
treatment
(including
reason-
able
diet,
weight
control,
and
physical
exercise)
and
drug
treat-
ment
(including
medicine
and
Chinese
medicine)."
Generally,
in
Qui
D,
et
al.
155
rural
areas
in
China
only
a
few
hypertension
patients
can
receive
treatments.
In
our
study,
there
were
2,592
(5.2%)
persons
who
had
histories
of
hypertension;
we
regarded
them
as
cases
of
hypertension.
We
found
that
both
the
'high-normal'
group
and
the
`hypertension
group'
showed
a
significant
increase
in
risk
of
CVD
mortality
rate.
It
has
been
suggested
that
diet
has
strong
relationship
with
CVD.'
Sodium
was
an
important
dietary
factor
of
CVD
mortali-
ty.
It
was
found
that
the
geographic
variations
in
salt
consumption
corresponded
somewhat
to
the
geographic
distribution
of
both
hypertension
and
CVD
(including
cerebral
infarction,
subarach-
noid
and
intracerebral
hemorrhage)
in
China.'
High
salt
intake
increased
the
risk
of
both
hypertension
and
CVD.
The
mechanism
by
which
sodium
may
cause
CVD
was
unclear.
It
was
reported
that
high
salt
intake
not
only
elevated
blood
pressure
by
expan-
sion
of
blood
volume,
but
also
caused
a
direct
damage
to
vessel
walls
through
the
acceleration
of
platelet
aggregation.'
A
restrict-
ed
salt
intake
trial
in
Tianjin
showed
that
blood
pressure
decreased
substantially
in
both
the
hypertensive
group
and
the
normotensive
group
when
following
a
low-sodium
and
high-
potassium
diet.'
In
a
case-control
study
in
rural
areas
in
China,
it
was
reported
that
there
was
a
significant
increase
in
the
risk
of
CVD
in
the
population
who
had
a
preference
for
salty
foods
(esti-
mated
daily
salt
intake
over
20g).
25
In
the
present
study,
we
found
that
reducing
the
degree
of
liking
for
salty
foods significantly
decreased
CVD
mortality
rate.
However,
we
found
significantly
inverse
association
between
frequency
of
Chinese
pickles
intake
and
CVD
mortality
rate.
We
supposed
that
people
who
had
high
frequency
of
Chinese
pickles
intake
were
usually
in
a
good
nutri-
tion
state
due
to
their
good
economic
status.
Another
reason
may
be
seasonal
variation
for
Chinese
pickles
intake.
Chinese
pickles
were
usually
taken
in
winter
and
early
spring
in
the
investigating
areas,
however
the
baseline
survey
was
performed
in
summer
or
autumn.
In
the
investigating
areas,
people
are
like
to
add
salt
to
daily
foods,
such
as
vegetables.
The
consumption
of
salt
in
rural
areas
in
Jiangxi
Province
was
19.2g
per
reference
man
per
day,"
which
was
higher
than
the
national
average
for
rural
areas
in
China
(13.9g
per
reference
man
per
day)."
This
might
be
related
to
the
fact
that
the
health
education
about
salt
intake
was
not
suf-
ficient
in
the
investigated
areas.
Meat
intake
was
an
important
protective
dietary
factor
of
CVD
mortality
in
our
study.
In
an
ecological
study
of
600
geographic
areas
within
Japan,
intake
of
animal
protein
appeared
to
have
a
protective
effect
on
CVD."
Our
study
also
found
that
the
risk
of
CVD
mortality
among
people
in
the
group
that
had
intake
of
meat
once
or
twice
per
month
was
significantly
decreased.
This
sug-
gested
that
insufficiency
of
animal
protein
was
a
risk
factor
for
CVD.
According
to
The
Dietary
and
Nutritional
Status
of
Chinese
Population
in
1992,
in
all
rural
areas
in
Jiangxi
Province,
only
4.7%
of
the
energy
source
was
from
animal
food."
The
protein
supplied
by
animals
was
only
9.9%,"
which
was
lower
than
that
in
rural
areas
in
China
nationwide
(12.4%),"
and
far
lower
than
that
in
Japan
in
1992
(53.0%)."
In
Japan
in
the
1960s,
low
serum
cholesterol
caused
by
insufficiency
of
animal
protein
and
by
high
intake
of
salt,
as
well
as
by
strenuous
labour-intensive
work,
ele-
vated
the
risk
of
cerebral
hemorrhage
in
rural
areas."
It
is
consid-
ered
that
the
higher
amount
of
death
from
cerebral
hemorrhage
(68.4%)
in
our
study
was
caused
by
insufficient
nutrition;
paral-
leling
conditions
similar
to
those
in
Japan
in
the
1960s."
No
sig-
nificant
association
was
found
between
liking
for
fatty
foods
and
risk
of
CVD
mortality
in
our
study.
Our
data
also
suggested
that
ex-drinkers
had
a
significantly
increased
risk
for
CVD
mortality
rate,
compared
with
non-
drinkers.
Ex-drinkers
often
had
health
problems
or
doctor-diag-
nosed
illnesses."
Increased
education
regarding
these
drinking-
related
illnesses
(coronary
heart
disease
for
instance)
that
might
encourage
patients
to
stop
drinking.
We
used
food
frequency
questionnaire
and
food
preference
questionnaire
in
our
study.
Quantitative
investigation
of
foods
should
also
be
conducted
in
order
to
give
concrete
information
to
be
used
for
directing
dietary
habits
in
these
areas.
ACKNOWLEDGEMENTS
We
thank
Prof.
Yutaka
Inaba
(Department
of
Epidemiology
and
Environmental
Health,
Juntendo
University
School
of
Medicine)
very
much
for
his
precious
instruction
and
suggestions.
We
also
thank
Haijiang
Liao
and
the
staff
of
Jiangxi
Center
for
Disease
Control
and
Prevention
for
their
assistance
in
data
collec-
tion
and
management
of
the
accomplishment
of
this
study.
REFERENCES
I.
Department
of
Control
Disease
of
MOH
Chinese
Academy
of
Preventive
Medicine.
A
series
of
reports
on
Chinese
disease
surveillance
(7):
1996
Annual
Report
on
Chinese
Disease
Surveillance.
Beijing,
The
Peking
Union
Medical
College
&
Beijing
Medical
University,
1998:2,41.
(in
Chinese)
2.
He
J,
Klag
MJ,
Wu
Z,
Whelton
PK.
Stroke
in
the
People's
Republic
of
China.
I.
Geographic
variations
in
incidence
and
risk
factors.
Stroke
1995;26:2222-7.
3.
Xu
Z,
Zheng
H,
Hu
D.
A
community
cohort
study
on
risk
factors
of
strokes
in
Shanghai:
a
Cox
regression
analysis
on
15,885
subjects.
Chin
J
Epidemiol
1994;15:94-8.
(in
Chinese)
4.
Ning
XJ,
Wang
JH,
Li
ZZ.
Epidemiology
of
stroke
in
urban
and
rural
areas,
Tianjin,
China:
a
six-year
prospective
research.
Chin
J
Epidemiol
1995;16:281-4.
(in
Chinese)
5.
State
Statistical
Bureau,
People's
Republic
of
China.
Statistical
yearbook
of
China
1994.
Beijing,
China
Statistical
Publishing
House,
1994:60,
278.
(in
Chinese)
6.
Cartography
Bureau
of
Jiangxi
Province.
Jiangxi
Province
atlas.
The
Atlas
Institute
of
the
People's
Republic
of
China,
1996.
(in
Chinese)
7.
Chinese
obesity
research
group,
Chinese
Agency
of
International
Life
Science
Institute.
Recommended
introduc-
tion
on
the
classification
of
the
body
mass
index
about
156
Cerebrovascular
Disease
in
China
Chinese
adult.
Chin
J
Prey
Med
2001;35:349-50.
(in
Chinese)
8.
Guidelines
Subcommittee
of
WHO-ISH.
1999
World
Health
Organization-International
Society
of
Hypertension
Guidelines
for
the
Management
of
Hypertension.
J
Hypertens
1999;17:151-83.
9.
The
collaborative
study
group
on
trends
of
cardiovascular
diseases
in
China
and
preventive
strategy.
Current
status
of
major
cardiovascular
risk
factors
in
Chinese
populations
and
their
trends
in
the
past
two
decades.
Chin
J
Cardiol
2001;29:74-9.
(in
Chinese)
10.
Liu
J,
Zhao
D,
Yao
CH,
Wu
GX,
Wang
W,
Zeng
ZC
et
al.
Trends
in
CVD
risk
factors
in
urban
and
rural
areas
of
Beijing
during
1984-1993.
Chin
J
Cardiol
2000;28:308-11.
(in
Chinese)
11.
Department
of
Control
Disease
of
MOH
Chinese
Academy
of
Preventive
Medicine.
A
series
of
reports
on
Chinese
disease
surveillance
(7):
1996
Annual
Report
on
Chinese
Disease
Surveillance.
Beijing,
The
Peking
Union
Medical
College
&
Beijing
Medical
University,
1998:
73,
82,
85.
(in
Chinese)
12.
Health
and
Welfare
Statistics
Division,
Minister's
Secretariat,
Ministry
of
Health
and
Welfare.
Age-adjusted
leading
causes
of
death
rates
special
report
on
vital
statistics
1970.
Tokyo,
Health
and
Welfare
Statistics
Association,
1974:
8,
28-29,
118-119.
(in
Japanese)
13.
Health
and
Welfare
Statistics
Association.
Journal
of
health
and
welfare
statistics
2002;
49:
52.
(in
Japanese)
14.
Ohsawa
T.
Visual
technology
for
being
changed
internal
diagnostic
medicine:
history
and
topics
from
X
ray
to
CT
and
MRI.
J
Jpn Soc
Intern
Med
2002;91:163-7.
(in
Japanese)
15.
Sacco
RL,
Benjamin
EJ,
Broderick
JP,
Dyken
M, Easton
JD,
Feinberg
WM,
et
al.
American
Heart
Association
Prevention
Conference.
IV.
Prevention
and
Rehabilitation
of
Stroke.
Risk
factors.
Stroke
1997;28:1507-17.
16.
Li
SC,
Schoenberg
BS,
Wang
CC,
Cheng
XM,
Bolis
CL,
Wang
KJ.
Cerebrovascular
disease
in
the
People's
Republic
of
China:
epidemiologic
and
clinical
features.
Neurology
1985;35:1708-13.
17.
Hart
CL,
Hole
DJ,
Smith
GD.
Risk
factors
and
20-year
stroke
mortality
in
men
and
women
in
the
Renfrew/Paisley
study
in
Scotland.
Stroke
1999;30:1999-2007.
18.
Haheim
LL,
Holme
I,
Hjermann
I,
Leren
P.
Risk
of
fatal
stroke
according
to
blood
pressure
level:
an
18-year
follow-
up
of
the
Oslo
Study.
J
Hypertens
1995;13:909-13.
19.
Antikainen
R,
Jousilahti
P,
Tuomilehto
J.
Systolic
blood
pres-
sure,
isolated
systolic
hypertension
and
risk
of
coronary
heart
disease,
strokes,
cardiovascular
disease
and
all-cause
mortali-
ty
in
the
middle-aged
population.
J
Hypertens
1998;16:577-
83.
20.
Eastern
Stroke
and
Coronary
Heart
Disease
Collaborative
Research
Group.
Blood
pressure,
cholesterol,
and
stroke
in
eastern
Asia.
Lancet
1998;352:1801-7.
21.
Ross
RK,
Yuan
JM,
Henderson
BE,
Park
J,
Gao
YT,
Yu
MC.
Prospective
evaluation
of
dietary
and
other
predictors
of
fatal
stroke
in
Shanghai,
China.
Circulation
1997;96:50-5.
22.
He
J,
Klag
MJ,
Wu
Z,
Whelton
PK.
Stroke
in
the
People's
Republic
of
China.
r
.
Meta-analysis
of
hypertension
and
risk
of
stroke.
Stroke
1995;26:2228-32.
23.
Ye
RG,
Lu
ZY,
Yu
WH,
Wang
ZL,
Liu
GL,
Liu
HY
et
al.
Medicine
(5th
Edition).
Beijing,
Publishing
House
of
People's
Health,
2001:264-8.
(in
Chinese)
24.
Gariballa
SE.
Nutritional
factors
in
stroke.
Br
J
Nutr
2000;84:5-17.
25.
Li
SC,
Wang
CC,
Fu
YG,
Cheng
XM,
Feng
EJ,
Wang
WJ,
et
al.
Risk
factors
for
stroke
in
rural
areas
of
the
People's
Republic
of
China:
results
of
a
case-control
study.
Neuroepidemiology
1990;9:57-67.
26.
Lai
FR.
Relationship
between
high
sodium
diet
and
hyperten-
sion
and
results
of
intervention
in
high
sodium
diet
popula-
tion.
Chin
J
Prey
Med
1992;26:168-70.
(in
Chinese)
27.
Ge
KY,
Zhai
FY,
Yan
HC,
Chen
L,
Guo
XG,
Wang Q
et
al.
The
dietary
and
nutritional
status
of
Chinese
population
(1992
National
Nutrition
Survey).
Beijing,
People's
medical
publishing
house,
1996:179.
(in
Chinese)
28.
Ge
KY,
Zhai
FY,
Yan
HC,
Chen
L,
Guo
XG,
Wang Q
et
al.
The
dietary
and
nutritional
status
of
Chinese
population
(1992
National
Nutrition
Survey).
Beijing,
People's
medical
publishing
house,
1996:109.
(in
Chinese)
29.
Omura
T,
Hisamatsu
S,
Takizawa
Y,
Minowa
M,
Yanagawa
H,
Shigematsu
I.
Geographical
distribution
of
cerebrovascu-
lar
disease
mortality
and
food
intakes
in
Japan.
Soc
Sci
Med
1987;
24:
401-7.
30.
Ge
KY,
Zhai
FY,
Yan
HC,
Chen
L,
Guo
XG,
Wang
Q
et
al.
The
dietary
and
nutritional
status
of
Chinese
population
(1992
National
Nutrition
Survey).
Beijing,
People's
medical
publishing
house,
1996:399.
(in
Chinese)
31.
Ge
KY,
Zhai
FY,
Yan
HC,
Chen
L,
Guo
XG,
Wang
Q
et
al.
The
dietary
and
nutritional
status
of
Chinese
population
(1992
National
Nutrition
Survey).
Beijing,
People's
medical
publishing
house,
1996:
329.
(in
Chinese)
32.
The
study
circle
for
Health
and
Nutrition
Information.
The
1998
National
Nutrition
Survey
in
Japan.
Tokyo,
Dai-ichi
shuppan
publishing.
Co.LTD,
2000:
133.
(in
Japanese)
33.
Komachi
Y.
The
future
of
community
health,
the
organiza-
tion
and
method
about
the
development
of
community
health.
Japanese
Journal
of
public
health
1990;
37:
365-73.
(in
Japanese)
34.
Shaper
AG.
Alcohol
and
mortality:
a
review
of
prospective
studies.
Br
J
Addict
1990;
85:
837-47.