Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain.
BMC Public Health. 2012 Mar 9;12:174. doi: 10.1186/1471-2458-12-174.
The cause of coronary disease inframortality in Spain is unknown. The aim of this study is to identify Spanish towns with very low ischemic heart disease mortality, describe their health and social characteristics, and analyze the relationship with a series of contextual factors.
We obtained the number of deaths registered for each of 8,122 Spanish towns in the periods 1989-1998 and 1999-2003. Expected deaths, standardized mortality ratio (SMR), smoothed Relative Risk (RR), and Posterior Probability (PP) of RR > 1 were calculated using Bayesian hierarchical models. Inframortality was defined as any town that displayed an RR below the 10th percentile, an SMR of under 1 for both sexes, and a PP of RR > 1 less than or equal to 0.002 for male and 0.005 for female mortality, during the two periods covered. All the remaining towns, except for those with high mortality classified as "tourist towns", were selected as controls. The association among socioeconomic, health, dietary, lifestyle and vascular risk factors was analyzed using sequential mixed logistic regression models, with province as the random-effects variable.
We identified 32 towns in which ischemic heart disease mortality was half the national rate and four times lower than the European Union rate, situated in lightly populated provinces spread across the northern half of Spain, and revealed a surprising pattern of geographic aggegation for 23 of the 32 towns. Variables related with inframortality were: a less aged population (OR 0.93, 95% CI 0.89-0.99); a contextual dietary pattern marked by a high fish content (OR 2.13, 95% CI 1.38-3.28) and wine consumption (OR 1.50, 95% CI 1.08-2.07); and a low prevalence of obesity (OR 0.47, 95% CI 0.22-1.01); and, in the case of towns of over 1000 inhabitants, a higher physician-population ratio (OR 3.80, 95% CI 1.17-12.3).
Results indicate that dietary and health care factors have an influence on inframortality. The geographical aggregation suggests that other factors with a spatial pattern, e.g., genetic or environmental might also be implicated. These results will have to be confirmed by studies in situ, with objective measurements at an individual level.
西班牙冠心病死亡率低的原因尚不清楚。本研究的目的是确定西班牙一些缺血性心脏病死亡率极低的城镇，描述其健康和社会特征，并分析与一系列环境因素的关系。
我们获得了 1989-1998 年和 1999-2003 年期间西班牙 8122 个城镇的死亡人数。使用贝叶斯层次模型计算了每个城镇的实际死亡人数、标准化死亡率比（SMR）、平滑相对风险（RR）和 RR>1 的后验概率（PP）。在两个研究期间，任何显示 RR 低于第 10 个百分位数、男性和女性 SMR 均低于 1 以及男性死亡率的 RR>1 的 PP 小于或等于 0.002 和女性死亡率的 PP 小于或等于 0.005 的城镇被定义为低死亡率。除死亡率高被归类为“旅游城镇”的城镇外，所有其他城镇均被选为对照。采用序贯混合逻辑回归模型，以省为随机效应变量，分析社会经济、健康、饮食、生活方式和血管危险因素之间的关系。
我们发现 32 个城镇的缺血性心脏病死亡率是全国平均水平的一半，比欧盟平均水平低四倍，这些城镇位于人口稀少的省份，分布在西班牙北部，其中 23 个城镇的地理聚集程度令人惊讶。与低死亡率相关的变量包括：人口年龄较小（OR 0.93，95%CI 0.89-0.99）；以鱼类含量高（OR 2.13，95%CI 1.38-3.28）和葡萄酒消费（OR 1.50，95%CI 1.08-2.07）为特征的环境饮食模式；肥胖的低患病率（OR 0.47，95%CI 0.22-1.01）；对于人口超过 1000 人的城镇，医生-人口比例较高（OR 3.80，95%CI 1.17-12.3）。
结果表明，饮食和医疗保健因素对低死亡率有影响。地理聚集表明，其他具有空间模式的因素，如遗传或环境因素，也可能与之相关。这些结果需要通过现场研究和个体水平的客观测量来证实。
