Heart Disease and Stroke in Neighbouring Countries
Heart Disease and Stroke in Neighbouring Countries
This study, examining the extent and pace of change in CHD and stroke mortality over time in two different countries on the same island, has shown striking similarities and some differences over the past 25 years. The decline in CHD mortality appeared to start earlier in NI, but by 2010 the two countries had similar overall reductions. The largest reductions for both CHD and stroke mortality in both countries was found in those aged 55–74 years. The main difference between the two countries for CHD mortality was for the youngest age group (25–54 years) where there appeared to be some levelling off in mortality in NI as observed elsewhere. For stroke mortality, the ROI has shown accelerated decline over the period 1985–2005, but this has levelled off sharply in more recent years, particular among women. The ROI rate is now similar to NI, which had been steadily declining over the study period.
The joinpoint regression method employed the permutation method and a maximum of three joinpoints over the period and therefore may have resulted in fewer inflection points being selected as a result. Also, there were changes between the versions of ICD coding (from V.9 to V.10) used to classify deaths at different points in time in the ROI (2004) and NI (2001) during the study period that might have led to artefactual changes due to shifts within the coding frame. However, it has been shown previously that CHD mortality coding discontinuities were minimal for both NI and the ROI.
Historically, the two countries have had high levels of CVD mortality and were among the highest in Europe, but, similar to most of Europe, mortality from CVD has been on the decline. Evaluation of trends comparing the two countries is complex, with broadly similar dietary and cultural factors, but differing healthcare systems and policies on CVD and risk factors, and the diverging pace of economic growth and political developments over the period.
Changing trends in CHD and stroke mortality have been broadly attributed to the common adverse lifestyles, including diets high in saturated fat and high levels of smoking. A comparison of risk factors in the mid-1980s with mid-1990s using the Kilkenny Health Project in the ROI and WHO MONICA Project in Belfast in NI found similar high levels of systolic blood pressure, cholesterol and smoking, with declines in most risk factors by the mid-1990s except for blood pressure in NI. NI's participation in WHO MONICA project, which ran from the mid-1980s to mid-1990s, and NI's involvement as the UK representative in WHO CINDI Programme generated considerable media coverage regarding high CVD rates in NI.
More recently, a report 'One Island—One Lifestyle?' compared risk factor levels using health surveys from 2007 (ROI) and 2005 (NI) and found similar levels of risk factors across the two countries. The levels of obesity were comparable at 24% and 25%, though the levels of sedentary behaviour were more marked in NI (29%) compared with the ROI (24%). Interestingly, the main differences in obesity levels were in the younger and older age groups, with NI showing higher levels in those 30–44 years (26%) compared with the ROI (22%) but lower levels in those 65+ years (23%) compared with the ROI (31%). These findings may explain, in part, the slowing down of CHD mortality in younger men in NI. Smoking rates from the same surveys were higher in the ROI at 29% compared with 26% in NI, with less smoking cessation advice provided in the ROI (34%) compared with NI (58%), and a stronger social gradient in the ROI. However, alcohol consumption was higher in NI compared with the ROI, with more reporting drinking weekly in NI (65%) compared with the ROI (46%) and above the weekly limit (19% vs 10% for NI and the ROI, respectively), but this may be due to the more detailed information available from NI surveys. Reported levels of eating a portion of fruit or vegetable at least once per day were higher in the ROI (fruit 83%; vegetable 95%) compared with NI (fruit and vegetable 58%), although the definitions differed in the surveys used.
Contributory risk factors were found to explain similar proportions of the decline in CHD mortality in both countries over the period 1985–2000 (ROI) and 1987–2007 (NI). Overall, 44% of the decline in the ROI and 35% in NI could be attributed to improvements in treatment uptake, and 48% and 60% to risk factor changes in the ROI and NI, respectively. Decreases in smoking prevalence explained 25.6% and 20.3% of the decline in CHD mortality and for cholesterol 30.2% and 25.8% in the ROI and NI, respectively. However, there was a larger difference for systolic blood pressure which had a greater reduction in NI than the ROI over the periods studied (28% compared with 6.1% in NI and ROI, respectively), although NI had higher levels of blood pressure in the initial year. This may help explain the flattening in stroke mortality observed in the ROI in more recent years. The Irish LongituDinal study on Ageing in the ROI (TILDA) found that 58% of men and 49% of women over 50 years were unaware they had hypertension as defined by the European Society of Cardiology criteria.
Contributions of increased treatment uptake to declining CHD mortality were also found to be similar between the two countries. Increased use of secondary preventative therapies was found to contribute to 15% and 18% of the mortality decline, and similarly, interventions including coronary artery bypass grafting and Percutaneous transluminal coronary angioplasty (PTCA) had relatively small contributions of 3% and 5% in NI and the ROI, respectively.
Different healthcare systems exist across the two countries, with a private (approximately 46% population coverage) and public mixed economy in the ROI and a public service in NI, free at the point of access (only 10% private healthcare in NI). In addition, NI has had a greater emphasis towards improving management of chronic disease in primary care. Despite this, the rate of GP consultation was found to be similar, with 74% of the population in the ROI and 73% in NI visiting their GP in the last year. Hospitalisation rates were also found to be similar.
Approaches to public health policy in the two countries show similarities and differences. In NI in 2001 a wide ranging 'Investing for health' public health policy framework was introduced across all Government Departments. From 2004, payment for performance (the Quality and Outcomes Framework) was introduced in NI as in the UK, which includes a structured approach to risk factor modification in marked contrast to the ROI. This was followed in 2009 by the development of a Service Framework for Cardiovascular Health and Wellbeing. No clear association is seen between these initiatives and the turning points in NI. In the ROI during the late 1980s, a general health policy and later a health promotion strategy were published. However, it was not until 1999 that the first national CHD strategy was published, followed by the more recent CVD policy (2010) which included stroke. The turning points for improvements in CHD and stroke mortality in the ROI are too early to be explained by the 1999 strategy but appear to coincide with increased economic growth during the 1990s and early 2000s. Others have reported that introducing innovation in medical care does not always coincide with improvements in cardiovascular mortality and that the effects are likely to be incremental over time.
While public policy over the last two to three decades in both countries has included food and nutrition advice as well as physical activity strategies, it is only in the last decade that obesity has largely gained strategic focus. The all island body, Safefood (http://www.safefood.eu), has launched several initiatives since its inception in 1999 with the aim of raising awareness of obesity and promoting healthy eating across both jurisdictions. Strategies tackling obesity and physical activity were instigated in both the ROI and NI in 2005.
There are several similar government initiatives in both countries including policies on taxation of smoking and alcohol. Similar policies on banning smoking in public places were adopted in both countries, though introduced at different times (March 2004 in the ROI, and April 2007 in NI). Changes in licensing laws in both countries have been accompanied by greater access to cheap alcohol and higher levels of consumption.
Historically, Ireland would have been considered economically disadvantaged, and NI one of the most disadvantaged areas in the UK. However, economic growth in both countries, followed by a recession more recently in the ROI, suggests a divergence in economic growth between the two countries. Although unemployment rates were similar in 1985 (16.7% ROI; 16.9% NI), 1990 (12.9% ROI; 11.6% NI) and 2000 (4.5% ROI; 6.6% NI), by 2010 a very different pattern had emerged with a doubling of rates in the ROI (13.6% ROI; 6.9% NI). Other studies have shown the link between prevailing economic conditions and health related outcomes, and the greater pace of decline and more recent levelling off in mortality trends in the ROI coincide with periods of rapid economic growth and subsequent economic recession as observed in Finland. Previous research on mortality trends across the island of Ireland (1989–1998) has shown threefold differences in mortality between the lowest and highest socioeconomic groups. In the UK, the social gradient in CHD mortality was found to be almost twofold in 2000 and 2007, with the greater accelerated decline in the most affluent group during this time.
The political landscape has also changed over time, particularly in NI, following a period of prolonged civil conflict from the 1970s referred to as 'the Troubles'. One reported effect of this period has already been shown, with poorer mental health in individuals who reported this had an important impact on them and the area in which they lived. The 'One-island One lifestyle?' report also examined differences in mental health and found evidence suggestive of higher levels of psychological distress in NI.
The strengths of the study are the similar quality and duration of mortality data available in both countries. The finding of a flattening in CHD and stroke mortality in some groups in recent years is supported by evidence from other studies and warrants further attention.
Discussion
This study, examining the extent and pace of change in CHD and stroke mortality over time in two different countries on the same island, has shown striking similarities and some differences over the past 25 years. The decline in CHD mortality appeared to start earlier in NI, but by 2010 the two countries had similar overall reductions. The largest reductions for both CHD and stroke mortality in both countries was found in those aged 55–74 years. The main difference between the two countries for CHD mortality was for the youngest age group (25–54 years) where there appeared to be some levelling off in mortality in NI as observed elsewhere. For stroke mortality, the ROI has shown accelerated decline over the period 1985–2005, but this has levelled off sharply in more recent years, particular among women. The ROI rate is now similar to NI, which had been steadily declining over the study period.
The joinpoint regression method employed the permutation method and a maximum of three joinpoints over the period and therefore may have resulted in fewer inflection points being selected as a result. Also, there were changes between the versions of ICD coding (from V.9 to V.10) used to classify deaths at different points in time in the ROI (2004) and NI (2001) during the study period that might have led to artefactual changes due to shifts within the coding frame. However, it has been shown previously that CHD mortality coding discontinuities were minimal for both NI and the ROI.
Historically, the two countries have had high levels of CVD mortality and were among the highest in Europe, but, similar to most of Europe, mortality from CVD has been on the decline. Evaluation of trends comparing the two countries is complex, with broadly similar dietary and cultural factors, but differing healthcare systems and policies on CVD and risk factors, and the diverging pace of economic growth and political developments over the period.
Changing trends in CHD and stroke mortality have been broadly attributed to the common adverse lifestyles, including diets high in saturated fat and high levels of smoking. A comparison of risk factors in the mid-1980s with mid-1990s using the Kilkenny Health Project in the ROI and WHO MONICA Project in Belfast in NI found similar high levels of systolic blood pressure, cholesterol and smoking, with declines in most risk factors by the mid-1990s except for blood pressure in NI. NI's participation in WHO MONICA project, which ran from the mid-1980s to mid-1990s, and NI's involvement as the UK representative in WHO CINDI Programme generated considerable media coverage regarding high CVD rates in NI.
More recently, a report 'One Island—One Lifestyle?' compared risk factor levels using health surveys from 2007 (ROI) and 2005 (NI) and found similar levels of risk factors across the two countries. The levels of obesity were comparable at 24% and 25%, though the levels of sedentary behaviour were more marked in NI (29%) compared with the ROI (24%). Interestingly, the main differences in obesity levels were in the younger and older age groups, with NI showing higher levels in those 30–44 years (26%) compared with the ROI (22%) but lower levels in those 65+ years (23%) compared with the ROI (31%). These findings may explain, in part, the slowing down of CHD mortality in younger men in NI. Smoking rates from the same surveys were higher in the ROI at 29% compared with 26% in NI, with less smoking cessation advice provided in the ROI (34%) compared with NI (58%), and a stronger social gradient in the ROI. However, alcohol consumption was higher in NI compared with the ROI, with more reporting drinking weekly in NI (65%) compared with the ROI (46%) and above the weekly limit (19% vs 10% for NI and the ROI, respectively), but this may be due to the more detailed information available from NI surveys. Reported levels of eating a portion of fruit or vegetable at least once per day were higher in the ROI (fruit 83%; vegetable 95%) compared with NI (fruit and vegetable 58%), although the definitions differed in the surveys used.
Contributory risk factors were found to explain similar proportions of the decline in CHD mortality in both countries over the period 1985–2000 (ROI) and 1987–2007 (NI). Overall, 44% of the decline in the ROI and 35% in NI could be attributed to improvements in treatment uptake, and 48% and 60% to risk factor changes in the ROI and NI, respectively. Decreases in smoking prevalence explained 25.6% and 20.3% of the decline in CHD mortality and for cholesterol 30.2% and 25.8% in the ROI and NI, respectively. However, there was a larger difference for systolic blood pressure which had a greater reduction in NI than the ROI over the periods studied (28% compared with 6.1% in NI and ROI, respectively), although NI had higher levels of blood pressure in the initial year. This may help explain the flattening in stroke mortality observed in the ROI in more recent years. The Irish LongituDinal study on Ageing in the ROI (TILDA) found that 58% of men and 49% of women over 50 years were unaware they had hypertension as defined by the European Society of Cardiology criteria.
Contributions of increased treatment uptake to declining CHD mortality were also found to be similar between the two countries. Increased use of secondary preventative therapies was found to contribute to 15% and 18% of the mortality decline, and similarly, interventions including coronary artery bypass grafting and Percutaneous transluminal coronary angioplasty (PTCA) had relatively small contributions of 3% and 5% in NI and the ROI, respectively.
Different healthcare systems exist across the two countries, with a private (approximately 46% population coverage) and public mixed economy in the ROI and a public service in NI, free at the point of access (only 10% private healthcare in NI). In addition, NI has had a greater emphasis towards improving management of chronic disease in primary care. Despite this, the rate of GP consultation was found to be similar, with 74% of the population in the ROI and 73% in NI visiting their GP in the last year. Hospitalisation rates were also found to be similar.
Approaches to public health policy in the two countries show similarities and differences. In NI in 2001 a wide ranging 'Investing for health' public health policy framework was introduced across all Government Departments. From 2004, payment for performance (the Quality and Outcomes Framework) was introduced in NI as in the UK, which includes a structured approach to risk factor modification in marked contrast to the ROI. This was followed in 2009 by the development of a Service Framework for Cardiovascular Health and Wellbeing. No clear association is seen between these initiatives and the turning points in NI. In the ROI during the late 1980s, a general health policy and later a health promotion strategy were published. However, it was not until 1999 that the first national CHD strategy was published, followed by the more recent CVD policy (2010) which included stroke. The turning points for improvements in CHD and stroke mortality in the ROI are too early to be explained by the 1999 strategy but appear to coincide with increased economic growth during the 1990s and early 2000s. Others have reported that introducing innovation in medical care does not always coincide with improvements in cardiovascular mortality and that the effects are likely to be incremental over time.
While public policy over the last two to three decades in both countries has included food and nutrition advice as well as physical activity strategies, it is only in the last decade that obesity has largely gained strategic focus. The all island body, Safefood (http://www.safefood.eu), has launched several initiatives since its inception in 1999 with the aim of raising awareness of obesity and promoting healthy eating across both jurisdictions. Strategies tackling obesity and physical activity were instigated in both the ROI and NI in 2005.
There are several similar government initiatives in both countries including policies on taxation of smoking and alcohol. Similar policies on banning smoking in public places were adopted in both countries, though introduced at different times (March 2004 in the ROI, and April 2007 in NI). Changes in licensing laws in both countries have been accompanied by greater access to cheap alcohol and higher levels of consumption.
Historically, Ireland would have been considered economically disadvantaged, and NI one of the most disadvantaged areas in the UK. However, economic growth in both countries, followed by a recession more recently in the ROI, suggests a divergence in economic growth between the two countries. Although unemployment rates were similar in 1985 (16.7% ROI; 16.9% NI), 1990 (12.9% ROI; 11.6% NI) and 2000 (4.5% ROI; 6.6% NI), by 2010 a very different pattern had emerged with a doubling of rates in the ROI (13.6% ROI; 6.9% NI). Other studies have shown the link between prevailing economic conditions and health related outcomes, and the greater pace of decline and more recent levelling off in mortality trends in the ROI coincide with periods of rapid economic growth and subsequent economic recession as observed in Finland. Previous research on mortality trends across the island of Ireland (1989–1998) has shown threefold differences in mortality between the lowest and highest socioeconomic groups. In the UK, the social gradient in CHD mortality was found to be almost twofold in 2000 and 2007, with the greater accelerated decline in the most affluent group during this time.
The political landscape has also changed over time, particularly in NI, following a period of prolonged civil conflict from the 1970s referred to as 'the Troubles'. One reported effect of this period has already been shown, with poorer mental health in individuals who reported this had an important impact on them and the area in which they lived. The 'One-island One lifestyle?' report also examined differences in mental health and found evidence suggestive of higher levels of psychological distress in NI.
The strengths of the study are the similar quality and duration of mortality data available in both countries. The finding of a flattening in CHD and stroke mortality in some groups in recent years is supported by evidence from other studies and warrants further attention.
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