Changes in Coronary Heart Disease Risk Among Japanese
2008; Lippincott Williams & Wilkins; Volume: 118; Issue: 25 Linguagem: Inglês
10.1161/circulationaha.107.750117
ISSN1524-4539
Autores Tópico(s)Health disparities and outcomes
ResumoHomeCirculationVol. 118, No. 25Changes in Coronary Heart Disease Risk Among Japanese Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBChanges in Coronary Heart Disease Risk Among Japanese Hiroyasu Iso Hiroyasu IsoHiroyasu Iso From Public Health, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Osaka, Japan. Originally published16 Dec 2008https://doi.org/10.1161/CIRCULATIONAHA.107.750117Circulation. 2008;118:2725–2729Heart disease is the second most prominent cause of mortality in Japan, and coronary heart disease (CHD) accounts for approximately half of heart disease–related deaths.1 The CHD mortality rate in Japan has been one-third to one-fifth that in the United States,1–5 even when validated fatal CHD and sudden cardiac deaths were compared.3–5 However, there is growing concern about a possible increase in the incidence of and mortality from CHD because of the westernization of lifestyles such as high-fat diets and sedentary work patterns associated with socioeconomic development since the 1960s.6–11The present report reviews original articles on population-based surveys of the mortality, incidence, and risk factors of CHD. It focuses on their trends since the 1960s because Japan has experienced rapid changes in lifestyles and environment accompanying socioeconomic development and maturation.MethodsTo identify the relevant literature, PubMed was searched for articles published from 1963 through June 2007. The following search key words were used: coronary heart disease or coronary artery disease or ischemic heart disease or myocardial infarction; mortality or incidence or risk factor; Japan or Japanese; and epidemiology. Bibliographies of key articles were reviewed and experts in the field were consulted to identify all of the major population-based studies.Trends in Mortality From CHDAge-adjusted mortality rates from CHD declined 50% for men and 65% for women between 1969 and 19928,9 and has continued to decline.1,2 According to the World Health Organization database, the age-adjusted annual CHD mortality rate in 2000 was 37 per 100 000 for men and 18 per 100 000 for women, which was the lowest among developed countries.2There are, however, sex, age, and regional variations in CHD mortality trends.9 The age-adjusted CHD mortality rates declined from 57 per 100 000 in 1969 to 1970 to 27 per 100 000 in 1991 to 1992 for men 30 to 69 years of age and from 26 to 9 per 100 000 for women of the same ages.8 The CHD mortality decline was smaller among men and women residing in the Tokyo and Osaka metropolitan areas than among those in the rest of Japan.9 Men 30 to 49 years of age in the metropolitan areas showed no substantial change in CHD mortality (≈10 per 100 000), whereas those in the rest of Japan showed a steady decline.9Trends in Incidence of CHDThere also were sex, age, and regional variations in CHD incidence trends reported from long-term population-based studies.10–14 Those studies used the systematic case ascertainment system, consistent diagnostic criteria, and a panel of physician-epidemiologists for final diagnosis to ensure the validity of CHD surveillance. The age-adjusted incidence of CHD among male employees 40 to 59 years of age in Osaka increased from 0.4 per 1000 person-years in 1963 to 1970 to 1.5 per 1000 person-years in 1979 to 1986 and then plateaued until 1987 to 1994.10More recently, Osaka male residents 40 to 69 years of age have shown a trend for CHD incidence to increase from 0.6 per 1000 person-years in 1980 to 1987 to 1.3 per 1000 person-years in 1996 to 2003.11 Male residents in Takashima City had an increasing incidence of CHD for all ages from 0.7 per 1000 person-years in 1990 to 1992 to 1.0 per 1000 person-years in 1999 to 2001; the CHD increase was observed primarily for those 65 years of age, and information on risk factor trends was not available.12However, the CHD incidence remained low and did not change materially among female residents in Osaka (≈0.4 per 1000 person-years)11 and Takashima (≈0.3 per 1000 person-years),12 nor did the incidence change over time among men and women 40 to 69 years of age in a rural community of Akita Prefecture (≈0.7 per 1000 person-years for men and 0.1 per 1000 person-years for women).7,11 No significant trends in CHD incidence were observed among the Hiroshima/Nagasaki cohort between 1958 and 1984 (≈2 per 1000 person-years for men and 0.8 per 1000 person-years for women of all ages),13 for the Hisayama cohort between 1961 and 2000 (≈2 per 1000 person-years in men and 1 per 1000 person-years in women ≥40 years of age),14 or for residents of Okinawa between 1998 and 1991 (myocardial infarction, ≈1 per 1000 persons-years for men and 0.04 per 1000 person-years for women ≥40 years of age).15Coronary Risk Factors and Their TrendsMajor risk factors for CHD from cohort studies and their trends from national studies and population-based studies were reviewed. Trends for the coronary risk factors were examined by use of the same standardized methods and criteria for blood pressure, smoking, overweight, alcohol intake, and diet and by the Centers for Disease Control–National Heart, Lung, and Blood Institute Lipid Standardization Program and the US Cholesterol Reference Laboratory Network for blood lipids.16Smoking and Its TrendThere was a consistent association between smoking and risk of incidence of or mortality from CHD.13,17–21 The multivariable hazard ratio of CHD incidence or mortality for current smoking compared with never or previous smoking was ≈2 to 3 for either sex, with a dose-response relationship between the number of cigarettes smoked and the risk of CHD.As for an effect of environmental tobacco smoke, age-adjusted CHD mortality was 30% higher for nonsmoking wives with husbands who smoked ≥20 cigarettes per day compared with those with nonsmoking husbands.22The risk of CHD was generally lower for ex-smokers than current smokers,18–20 which suggests that smoking cessation lowers risk. A recent large cohort study showed that a decline in risk of CHD after smoking cessation occurred within 2 years and reached the level for never smokers 10 to 14 years after cessation.23 In that study, the benefit of smoking cessation was observed similarly among the 40-to-64- and 65-to-79-year age subgroups. The benefit of smoking cessation also was confirmed for patients with a history of myocardial infarction for the prevention of subsequent cardiac events.24In Japan, the prevalence of current smoking has declined from 82% in 1965% to 46% in 2005 for men ≥20 years of age, whereas that for women declined slightly from 16% in 1965% to 12% in 2005.1,25 However, for women 20 to 29 years old, the prevalence of smoking increased from 7% in 1965 to 21% in 2005.1,25 Population-based studies have identified similar downward trends in smoking for middle-aged men.10,11High Blood Pressure and Its TrendHigh blood pressure has been identified as a risk factor for CHD,13,26,27 and both systolic and diastolic blood pressure levels were positively associated with CHD risk.13,26 The multivariable hazard ratio of CHD incidence for high blood pressure (systolic blood pressure ≥135 mm Hg, diastolic blood pressure ≥85 mm Hg, and/or use of antihypertensive medication) was ≈2 for men and 1.5 for women.28According to a national survey, mean systolic blood pressure for persons ≥30 years of age declined from 142 mm Hg in 1961 to 137 mm Hg in 2000 for men and from 141 to 132 mm Hg for women,29 whereas changes in mean diastolic blood pressure levels were not substantial: from 82 to 83 mm Hg for men and from 81 to 78 mm Hg for women.29 The prevalence of high blood pressure (systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg) in 2000 was 52% for men and 40% for women ≥30 years of age.29Similar blood pressure declines were observed between the 1960s and the 1990s in population-based studies of rural men and women and urban women.11 For urban men, either residents or company employees, systolic blood pressure declined modestly between the 1960s and the 1990s, but diastolic blood pressure started to increase in the 1980s.10,11 The prevalence of hypertension decreased, along with downward trends in mean systolic blood pressure levels.10,11 The prevalence of antihypertensive medication use rose substantially between the 1960s and the 1970s but did not change substantially thereafter.7,10,11Blood Lipids and Their TrendsHigh serum total cholesterol has been a risk factor for CHD.3,13,19,28,32–34 Serum total cholesterol levels were positively associated with risk of CHD, although mean levels of total cholesterol are lower in Japan than in Western countries.13,19,32–34 The multivariable hazard ratio of CHD mortality for high (≥220 mg/dL) compared with lower (<180 mg/dL) total cholesterol was 1.6 to 1.8 for both men and women,19 whereas that for very high (≥260 mg/dL) compared with very low (<160 mg/dL) total cholesterol was ≈3.5 for both men and women.33,34Serum high-density lipoprotein (HDL) cholesterol was inversely associated with risk of CHD.19 Nonfasting serum triglycerides also were associated with the risk of CHD even after adjustment for HDL cholesterol and other coronary risk factors.35According to a national survey, mean total serum cholesterol levels increased from 186 mg/dL in 1980 to 200 mg/dL in 2000 among men ≥30 years of age and from 191 to 208 mg/dL among women of the same age.29 The prevalence of high total cholesterol (≥220 mg/dL) increased from 15% to 27% for men and 19% to 35% for women, and that of total cholesterol ≥260 mg/dL increased from 2% to 5% for men and from 3% to 8% for women.29 The increase in total cholesterol levels and prevalence of high total cholesterol was observed primarily between the 1980s and the 1990s and plateaued thereafter. Mean serum HDL cholesterol levels have been higher for Japanese than for whites36 and increased from 50 mg/dL in 1990 to 53 mg/dL in 2000 for men and from 53 to 61 mg/dL for women.29 In addition, mean serum triglyceride levels increased between 1990 and 200 for both men and women.29Similar trends in blood lipids were observed in population-based studies of men and women in rural and urban communities and of male employees in metropolitan areas between the 1960s and the 2000s7,10,11 and in a large hospital/clinic-based study.37 The prevalence of the use of lipid-lowering medication increased over time by up to 3% for men and 9% for women, although it was much lower than that of antihypertensive medication.10,11Diabetes Mellitus and Its TrendNon–insulin-dependent diabetes mellitus may be a risk factor for CHD, although the evidence from community-based cohort studies has been limited. The CHD incidence was twice as high for diabetics as nondiabetics.38 The multivariable hazard ratio of CHD mortality for diabetics (casual blood glucose ≥200 mg/dL and/or history of diabetes) was ≈1.5 for men and 2.5 for women,39 and that for diabetics (fasting glucose ≥140 mg/dL, nonfasting glucose ≥200 mg/dL, and/or on treatment) compared with nondiabetics (fasting glucose <100 mg/dL or nonfasting glucose 5 versus 0 to 2 times per week was ≈0.6; that for the highest versus the lowest quintiles of isoflavone intake was 0.4 for women, but men did not show such associations. The inverse association between isoflavone intake and risk of myocardial infarction was observed primarily among postmenopausal women.51According to the national nutrition survey, mean fish intake for adult men and women was ≈80 g/d in the 1960s and 90 g/d between the 1970s and the 2000s.52 Mean intake of beans was ≈70 g/d and did not change over time.52Physical Activity and Its TrendPhysical activity was associated with a reduced risk of CHD mortality.53 The multivariable hazard ratios of CHD mortality for the highest versus the second-lowest category of walking (≥1.0 versus 0.5 h/d) or sports participation (≥5 versus 1 to 2 h/wk) were ≈0.8 and 0.5, respectively.53No robust data are available for long-term trends in physical activity. However, a decline in physical activity is suggested, particularly for men, because of the stable or declined energy intake,52 the increased BMI,29,45 the mechanization of the work environment, and motorization.7DiscussionJapan is unique among developed countries in that, since the 1960s, it has had the lowest mortality from CHD, according to vital statistics1,2 and population-based studies,3–5 which has been further declining for both men and women.8,9 Mean systolic blood pressure levels7,9–11,13,29 and the prevalence of smoking1,10,11,25 declined, but mean serum total cholesterol and triglyceride7–11,29,37 levels increased for both men and women. The decline in CHD mortality is attributable to large declines in blood pressure levels and the prevalence of smoking, which may have offset the potentially adverse effects of increased total cholesterol levels during the past decades. High total cholesterol would need a longer incubation period to maximize the effect on CHD risk.54,55Trends in CHD mortality and coronary risk factors have not been uniform and may vary by sex, age, and region. In the 2 largest metropolitan areas, Tokyo and Osaka, where 17% of the total Japanese population resides, the CHD mortality decline was small for men 30 to 49 years of age compared with those residing in the rest of Japan.9The higher sustained cholesterol levels, together with a recent rise in diastolic blood pressure and declines in systolic blood pressure levels and the prevalence of smoking, may explain in part the slowed decline in CHD mortality in middle-aged urban men compared with rural men. Urban men have a higher fat intake than rural men (22% to 26% versus 19% of total energy for men 40 to 59 years of age)10,11 and lower physical activity (1600 versus 1800 calories consumed per day).56 According to an autopsy study,57 the pathology of myocardial infarction among urban men was larger infarction associated with hypercholesterolemia-derived atherosclerosis of coronary arteries as also observed in Western populations, whereas for rural men, the pathology of myocardial infarction was smaller, disseminated infarction associated with hypertension-derived atherosclerosis of coronary arteries.The annual CHD incidence rate for middle-aged Japanese was ≤2 per 1000 for men and ≤1 per 1000 for women; that for Americans was 5 to 6 per 1000 for men and 2 to 3 per 1000 for women.58,59 The low CHD incidence for Japanese men and women is explained by more favorable lipid profiles and glucose metabolism, along with lower BMI levels. Lifestyle factors, including low total and saturated fat intakes7,8,10,55,60 and high fish50,52 and soy intakes51,52 for men and women, as well as light to moderate alcohol intake49,61 for men, may be major contributing factors.There were sex, age, and area variations in trends in CHD incidence. The CHD incidence tripled among urban male employees 40 to 59 years of age between the 1960s and the 1990s, subsequently doubled for urban male residents 40 to 69 years of age between the 1980 and the 2000s, and increased by ≈50% for rural or semiurban male residents of all ages.12 The number of CHD incident cases was too small to draw definite inferences from previous trend studies.10–12 However, the CHD increase was consistent with findings of a Japanese migrant study that the incidence of CHD was higher among Japanese men living in Hawaii and California than among Japanese men living in Japan.62 The gradient of CHD incidence corresponded to the difference in saturated fat intake and serum total cholesterol levels, supporting environmental effects on CHD risk.62 For female residents and rural male residents, there was no material change in CHD incidence.7,11–14The decline in CHD mortality, in conjunction with an increase or no change in CHD incidence in Japan, may be accounted for by improvements in medical treatment for CHD and/or decreased severity of CHD during the past decades. In fact, the number of emergency medical centers equipped with an intensive care unit or a cardiac care unit in Japan stood at 17 in 1978, 103 in 1989, and 201 in 2007.1 In addition, the in-hospital case fatality rates at hospitals with cardiac care units declined by >50% between the early 1980s and the late 1990s, probably because of improvements in treatment, including thrombolytic therapy and percutaneous transluminal coronary angioplasty.63There is no robust evidence on long-term changes in the severity of CHD. A series of autopsy studies showed a decline in the coronary atherosclerosis score for Japanese men and women between the 1960s and the 1980s,64 suggesting that the severity of CHD may have declined in association with major declines in blood pressure levels and the prevalence of smoking.The risk of CHD mortality and its incidence for Japanese women are half or lower than for Japanese men. The probable reason for the lower CHD risk among women is the lower coronary risk factors such as blood pressure levels, serum triglycerides, and the prevalence of smoking and diabetes mellitus and the higher levels of serum HDL cholesterol. Serum total cholesterol levels are lower in premenopausal women but higher in postmenopausal women compared with men of the same age group. However, the premenopausal lower total cholesterol levels may have a major impact on the sex difference in CHD because increased cholesterol levels after menopause probably would not be around long enough to lead to the development of CHD in many Japanese women.The percentages of preventable CHD were 45% in men and 18% in women for control of smoking, 34% in men and 17% in women for control of hypertension, 5% in men and 8% in women for control of hypercholesterolemia (≥260 mg/dL), and 5% in men and 9% in women for control of diabetes mellitus. These percentages were estimated from the population-attributable risk percent65 using data on hazard ratios (for current smoking, 2.5 in both men and women; for high blood pressure, 2 in men and 1.5 in women; for hypercholesterolemia, 3.5 in both men and women; and for diabetes, 1.5 in men and 3 in women) and prevalence of risk factors (for current smoking, 54% in men and 15% in women; for high blood pressure, 52% in men and 40% in women; for hypercholesterolemia, 2.0% in men and 3.4% in women; and for diabetes, 10% in men and 5% in women). Therefore, most of the male CHD cases (461 000 patients and 41 970 deaths in 2005)1,66 and half of the female CHD cases (403 000 patients and 34 533 deaths in 2005)1,66 in Japan would be preventable if these major coronary risk factors were controlled.ConclusionsThis review presented distinctive trends for the mortality from, incidence of, and risk factors for CHD in Japan. 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