Glucose intolerance as contributor to noncommunicable disease morbidity and mortality. WHO integrated program for community health in noncommunicable diseases.

The World Health Organization (WHO) has considerable evidence that several interrelated factors (e.g., smoking, hypertension, cholesterol, and obesity) contribute to total mortality. Data are presented documenting that glucose intolerance is also a risk factor for total mortality, as well as for cancer and cardiovascular morality. The Kaunas-Rotterdam Intervention Study, which documented glucose tolerance and mortality in a cohort of men, shows a linear increase in total mortality with increasing blood glucose levels. By use of multiple logistic regressions, glucose was shown to be a significant risk factor (c = .2534, t = 4.0) for total mortality. A paradigm is presented in which diabetes is placed as a disease and glucose intolerance as a risk factor within the total scheme for the development of noncommunicable diseases. The WHO action plan for integrated programs in noncommunicable diseases is discussed. The program expands on the experience gained by WHO investigators in community programs and proposes a cooperative effort globally in community-based programming.

The WHO multinational study of vascular disease in diabetes: 1. General description.

A general description of the multinational study under the auspices of the World Health Organization is presented. The purpose was to compare the prevalence of vascular disease in representative samples of diabetic subjects of different ethnic and cultural habitus. Standardized methods of investigation were devised. Fourteen centers participated, and the data collected so far indicate that the characteristics of the populations studied varied as to age composition, adiposity, cigarette smoking, treatment, age at diagnosis, and duration of diabetes. Thus, taking these factors into consideration and while awaiting completion of the data, conclusions must be drawn with reserve.

The role of circulating glucose and triglyceride concentrations and their interactions with other "risk factors" as determinants of arterial disease in nine diabetic population samples from the WHO multinational study.

In 9 of the 14 national samples of diabetic patients assembled for the WHO Multinational Study of Vascular Disease in Diabetes additional laboratory data made it possible to relate manifestations of macrovascular disease to blood glucose concentrations as well as to diabetes duration and to other potential determinants. In five of the samples, serum triglyceride concentrations were also measured and were included in simple and multivariate analyses. Ischemic heart disease defined from Minnesota-coded EKGs and standardized WHO questionnaires was more strongly associated with serum triglyceride concentrations than with serum cholesterol concentrations, an association less notable in non-insulin-dependent diabetic patients. Ischemic heart disease was not related to the single fasting plasma glucose estimated for this study. Stroke and amputation were much more strongly related to the known duration of diabetes than was ischemic heart disease, and they were both related to blood glucose concentration measured at the time of study. Despite major variation in arterial disease prevalence rates between collaborating centers, risk for diabetic women appeared to equal that for diabetic men. The major variation in arterial disease prevalence between national groups could be accounted for only in part by the risk factors studied. Other factors, genetic or more likely environmental, are likely to contribute to the variation in arterial disease susceptibility and, if definable, may be potentially preventable.

Differences in mortality and coronary heart disease between Lithuania and The Netherlands: results from the WHO Kaunas-Rotterdam Intervention Study (KRIS).

BACKGROUND: A 9.5-year follow-up of the Kaunas-Rotterdam Intervention Study (KRIS) provided an opportunity to compare mortality patterns and rates in a population from Lithuania, one of the former republics of the Soviet Union, with a population from the Netherlands. These populations consisted of 2452 and 3365 males, respectively, aged 45-60 years. In 1972-1974, these males were extensively screened for cardiovascular risk factors, using uniform methods. METHODS AND RESULTS: During the follow-up, 303 males in Kaunas (Lithuania) and 350 males in Rotterdam (the Netherlands) died. Using Cox proportional hazards and logistic regression analysis, it was found that all-cause mortality rates during follow-up were 30% higher in Kaunas; this was mainly due to higher mortality rates from external causes (relative risk = 6.69), stomach cancer (RR = 2.78), stroke (RR = 2.30) and infectious diseases (RR = 12.43). The risk of fatal and non-fatal coronary heart disease (CHD) was, however, smaller in Kaunas (RR = 0.72). This lower risk closely corresponded with the Lithuanian risk profile which could be described by less smoking, lower cholesterol levels, and higher physical activity. As Lithuanians had a more advantageous cardiovascular risk profile, the higher Lithuanian all-cause mortality rates could not be explained by this risk profile. CONCLUSIONS: The results provide evidence for geographical differences in mortality and morbidity between Lithuania and the Netherlands. Population-specific health behaviours were shown to be involved in differences in the risk of CHD. The lower CHD rates in Eastern European communities in the 1970s, in this study confirmed for Lithuania, suggests that the apex of the CHD epidemic had not yet reached the Lithuanian population.

Educational level of spouses and risk of mortality: the WHO Kaunas-Rotterdam Intervention Study (KRIS).

BACKGROUND: A 9.5-year follow-up of the Kaunas-Rotterdam Intervention Study (KRIS) provided the opportunity of investigating whether the educational level of wives was associated with their husbands' risk of mortality and coronary heart disease (CHD), independently of the educational level of the husbands themselves. METHODS: The data represent populations consisting of 2452 Lithuanian men and 3365 Dutch men. These men were extensively screened for cardiovascular risk factors in the period 1972-1974. During the follow-up 303 Kaunasians and 350 Rotterdammers died. We used the Cox proportional hazards and the logistic regression models to analyse the data. RESULTS: We found that men whose spouses had little education apparently had an increased risk of all-cause mortality, even when their own educational level was taken into account. The relative risks (RR) were 1.57 in Kaunas and 2.15 in Rotterdam. The results for fatal and non-fatal myocardial infarctions were compatible with this finding, especially in Rotterdam. The prevalence of smoking was higher among men whose wives had primary schooling only. Nonetheless, adjusting the effect of the wife's educational level on her husband's mortality risk for all coronary risk factors in the husband only partially explained the association. CONCLUSIONS: The spouse's educational level appears to have independent effects on a man's risk of mortality in both eastern and western European communities. The results strongly suggest that including characteristics of the socioeconomic status of an individual's spouse would improve studies of socioeconomic differences in health.

Low physical activity and worsening of glucose tolerance: results from a 2-year follow-up of a population sample in Malta.

The relationship between the level of habitual physical activity and glucose intolerance was examined cross-sectionally and during a 2-year follow-up among a sample of 388 subjects in Malta. At baseline, the subjects were classified into three categories of physical activity, which was inversely related to the 2-h post challenge blood glucose (P = 0.02). In a multivariate analysis, age (standardized regression coefficient 0.23; P less than 0.001), family history of diabetes (0.20; P less than 0.001), and physical activity (-0.18; P = 0.002) were the strongest predictors of the 2-h blood glucose at baseline. The age standardized 2-year risk of glucose intolerance, i.e. impaired glucose tolerance or diabetes was consistently and inversely related to the level of physical activity. Among subjects with normal glucose tolerance at baseline (n = 127) those with low physical activity had a 2.7 times higher risk of glucose intolerance during follow-up than those with high physical activity (P = 0.1), and even a 3.7-fold risk of glucose intolerance at baseline (n = 196) when both the subjects with normal and impaired glucose tolerance at baseline were considered together (P = 0.005). Similar trends were observed for the risk of diabetes. The suggested protective effect of physical activity was independent of body mass, a family history of diabetes and gender. Within the limits of this small study we conclude that physical activity may have some importance in the primary prevention of impaired glucose tolerance and, possibly, non-insulin-dependent diabetes mellitus.

Self-rated health and mortality in a Lithuanian and a Dutch population.

The hypothesis that the evaluation of one's health as poor is associated with mortality, independent of the results of a standardized medical examination, was tested in the Kaunas-Rotterdam Follow-Up Study. In this study two cohorts, one consisting of 2452 Lithuanian males and one of 3365 Dutch males, aged 45-60, were screened for cardiovascular risk factors in 1973, using identical protocols, and were followed for about ten years. Self-rated health was assessed by two direct questions: 'How would you assess your own health?' and 'What do you think of your own health compared to that of other men of your age?' as well as by a Semantic Differential Test of 'My Health'. In both cohorts a negative evaluation of one's health was associated with mortality, controlling for past or present heart disease, cardiovascular risk factors, parental life span, socio-economic and marital status. Especially the data with regard to the comparative question indicate that self-rated health is associated with mortality in men living in two different socio-cultural systems. The date suggest that a weak sense of mastery may explain the association between health perception and mortality.

Comparative data on diet and risk factors from five Eastern European communities.

Starting from large differences in rates and trends of mortality between European countries, an ecological type of comparative study was launched between five population samples in so-called Eastern European countries: Krakow, Warsaw, Novosibirsk, Kaunas, and the German Democratic Republic (GDR). The purpose was to look into dietary data as a possible explanation for varying risk factor and mortality data. It was found that high energy and fat consumption but low carbohydrate intake are common in these populations. The sources of energy and fat however vary markedly. An association was found between diet-related cardiovascular risk factors like the mean total cholesterol value and excess energy or fat intake both in males and in females. It was concluded that changes in diet might be the most important prerequisite for a number of lifestyle changes in these communities, and that those diet changes need to be monitored on a regular basis as part of the national health reports.

[Chief risk factors of ischemic heart disease and mortality of the middle-aged male population of Kaunas]. / Osnovnye faktory riska ishemicheskoi bolezni serdtsa i smertnost' muzhskogo naseleniia srednego vozrasta Kaunasa.

A prospective study, averaging 11 years, of a representative sample of 2455 male residents of Kaunas between 45 and 59 years of age has explored relationships between coronary risk factors and mortality due to coronary heart disease (CHD), cancer, injuries, as well as total mortality rates. An original analytical approach has been developed for the analysis of associations between individual risk factors and mortality that allows to exclude the effects of age and other examined factors. A marked relationship has been demonstrated between: coronary mortality and age, arterial blood pressure, cholesterol, glucose tolerance, smoking, body weight, the presence and clinical form of CHD; cancer-related mortality, and age or smoking; traumatic mortality and smoking; total mortality and age, arterial blood pressure, glucose tolerance, body weight, smoking, and the presence and type of CHD.

[Risk of ischemic heart disease development in 45- to 59-year-old men. The results of a 5-year observation in the Kaunas population study]. / Risk razvitiia ishemicheskoi bolezni serdtsa u 45-59-letnikh muzhchin. Rezul'taty 5-letnego nabliudeniia Kaunasskogo populiatsionnogo issledovaniia.

The possibility of prognosticating the development of ischemic heart disease in persons clinically healthy in respect of this illness was studied. The data on 1,977 males were used, among whom, according to the registers of myocardial infarction and deaths, 34 had suffered from ischemic heart disease in a follow-up period of 5 years. The prognosis was made on the basis of logistic function and the following 6 signs: age, systolic pressure, cholesterol content, smoking, blood sugar level, body mass index. In the upper decile of the assessment of the probability of ischemic heart disease development, 47% of cases with this disease were encountered, i. e. 10% of clinically healthy individuals were distinguished among whom the risk of the development of ischemic heart disease was 8 times that among the remaining persons (0.081 and 0.01, respectively).

[Methodical study of multifactorial prevention of ischemic heart disease]. / Metodicheskoe issledovanie po mnogofaktornoi profilaktike ishemicheskoi bolezni serdtsa.

The purpose of the investigation was to study the possibilities of involving the population at large in mass screening procedures, the possible classification of the population with regard the degree of risk of ischaemic heart disease, and the potentials of its preventive therapy. The examined contingent was classified with due regard to some risk factors (arterialy hypertension, hypercholesterolemia, imparied glucose tolerance) and pathological states. The final grouping of the contingent was as follows: the group of "normal" was comprised by 53.4% of the examined, the "intermediate"-18.6%, the "pathological"-28%. The "intermediate" group comprised 350 persons selected for preventive therapy by a double blind method. Surveillance of 10% of those in the "normal" group and the whole "pathological" group was arranged.

[Participation of the population in mass screening and the role of complete population surveillance for detection of the disease studied (from the experience of the methodical measures for the prevention of ischemic heart disease in Kaunas)]. / Ob uchasti naseleniia v massovykh profilakticheskikh osmotrakh i roli polnoty okhvata naseleniia obsledovaniem dlia vyiavleniia izuchaemogo zabolevaniia (iz opyta kaunasskogo metodicheskogo issledovaniia po profilaktike ishemicheskoi bolezni serdtsa.

A comparison of the results of examination of 100 individuals, some of whom had taken part in the survey while the others had refused it and information about them was specially obtained by other means (in some cases by collecting the medical documentation), is presented. Factors conducive to the development of ischemic heart disease predominated among individuals who refused to take part in the survey. The incidence of ischemic heart disease and arterial hypertension was also higher among them. It is concluded that individuals who refuse examination during preventive survey form a group with a high risk of the development of ischemic heart disease; this group should be taken into account when therapeutic and preventive measures are conducted among the population.

[Comparison of the behavior characteristics of men smokers and nonsmokers]. / Sopostavlenie povedencheskikh kharakteristik kuriashchikh i nekuriashchikh muzhchin.

The authors studied the relationship of smoking with the behavioristic and psychological parameters in men aged 40-59, 3713 inhabitants in Kaunas who participated in the program of multifactorial prevention of ischaemic heart disease. The comparison of groups of men who had never smoked, of those who gave up the habit and the smoking group showed that the smokers had a lower intellectual level and exhibit a negativistic attitude toward medicine and the preventive measures. It is difficult to convince the smokers to come for the health check-ups (p less than 0.0001) as compared to the other groups. Individuals who gave up smoking show themselves to be more cooperative, however their anamnestic data as to health are worse than in the other two groups.

[Division of the 45- to 59-year-old male population into groups depending on the risk factors in a prophylactic study of ischemic heart disease]. / Delenie 45--59-letnego muzhskogo naseleniia na gruppy v zavisimosti ot faktorov riska v profilakticheskom issledovanii ishemicheskoi bolezni serdtse.

A prospective study was conducted from March 1972 to November 1976 in a group of Kaunas male population ranging in age from 45 to 59 years. At the beginning of the study it consisted of 3,553 individuals. They were divided into groups of low, moderate, and high risk according to the presence of a risk factor (hypertension, hypercholesteremia, impaired glucose tolerance test) and a pathologic condition. The ratio of the total mortality rate per 1,000 of the population during the observation period in these groups was 1 : 2 : 3, while that of the mortality of ischemic heart disease was 1 : 3 : 5. The rate of out-patient coronary mortality and the occurrence of new cases with myocardial infraction according to their number registered in the groups of low, moderate, and high risk was 1 : 2 : 5. All the indices in the group of individuals who refused to take part in the study were close to those in the high risk group. The data obtained point to the possibility of defecting by means of preventive study individuals exposed to a greater or lesser risk of the development of ischemic heart disease and death, which makes it possible for the Public Health Service to concentrate attention of definite groups of the population so as to apply differentiated preventive measures.

[Physicians' knowledge on the questions of primary prevention of cardiovascular and other chronic noninfectious diseases]. / Osvedomlennost' vrachei v voprosakh pervichnoi profilaktiki serdechno-sosudistykh i drugikh khronicheskikh neinfektsionnykh zabolevanii.

The attitude of physicians to the problems of primary prevention, their knowledge of general risk factors (RF) of chronic noncommunicable diseases (CNCD) and the presence of RF among physicians were studied using the questionnaire method. Altogether 275 physicians from 5 rural areas were interviewed within the framework of the Integrated Program on CNCD Prevention in the Lithuanian SSR, i. e. 74.5% of the total number of physicians. Half of them took a positive attitude to primary preventive measures of CNCD. Therapeutists were better aware of risk factors and the criteria of their assessment as compared to physicians of the other specialities. The assessment of RF levels among physicians (filling in questionnaire forms) showed that 29.6% of men and 2.4% of women were regular smokers, 7.3% of women and 4.6% of men had excess body mass (a body mass index exceeding 30 kg/m2). A high prevalence of smoking among male physicians pointed out a necessity of preventive measures among them.

[Risk factors in chronic noninfectious diseases among the population of the Lithuanian SSR]. / Faktory riska khronicheskikh neinfektsionnykh zabolevanii sredi naseleniia Litovskoi SSR.

Prevalence of risk factors (RF) for chronic noncommunicable diseases (CND) such as hypertension, overweight and smoking among random samples of the representative population of various age groups in the Lithuanian SSR was considered. A total of 12126 males and females were examined. CND risk factors were found in all age groups without significant differences among separate administrative areas of the republic. Age-adjusted rates of RF levels were presented. Hypertension was found in 16.18% of males and 16.19% of females. There was a 2.7-fold and 8.2-fold age-linked increase in hypertension among the male and female population, respectively. Smoking was the most common RF among males (54.3%) while in females it reached 8.9%. With age the number of smokers tended toward reduction: among males 1.5 times and in females 2.2 times. Overweight was found to be the most prevailing RF among females (48.33%) while among the male population it was 27.9%. In the older age group overweight was observed in every other male and in two out of three women.

Health policy development in Lithuania.

The process of formulating a national health policy in Lithuania, a country in transition, has undergone several stages. Despite the existence of a national critical mass of professionals who understand the major principles of health policy development and who have a solid database to scientifically back the suggested decisions, and despite general acceptance by the public of the broader dimensions of health, the actual process of developing health policy is still facing considerable difficulty. Many factors obstruct this process, such as the inflexibility and resistance of the medical profession, traditions from the previous health service model and an extremely difficult economic situation. Nevertheless, one of the most important factors is the frequent change of government and, subsequently, of ministers of health, which makes continuity difficult. Fortunately, however, in contrast to the political level, the health professionals involved in health policy development and implementation assure at least one level of this necessary continuity. As a result of continuous efforts by the Health Reform Management Group and research and education institutions, and with the constant support of WHO, a policy and strategy for health for all continues to be developed, and the groundwork is being laid for improved dialogue and participation.