Daily variations in deaths in Lithuania: the possible contribution of binge drinking

Laurent Cheneta, Annie Brittona, Ramune Kaledieneb and Jadvyga Petrauskieneb

a European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London WC1B 3DP, UK
b Kaunas University of Medicine, Mickevicius St 9, 3000 Kaunas, Lithuania.


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
Background During the early 1990s the countries of the Former Soviet Union experienced a dramatic rise in mortality, especially from cardiovascular diseases. Although still poorly understood there is evidence, particularly from Russia, that this mortality crisis is partly linked to alcohol consumption. In this paper we use data from Lithuania to explore the daily variations of deaths and the probable relationship with binge drinking.

Methods Computerized death certificates for those aged 20–59 years were analysed according to the day of death, place of death, and cause of death for the years 1988–1997.

Results There is a marked increase in deaths from accidents, violence, and alcohol poisoning at the weekend, suggesting a pattern of binge drinking in Lithuania. There is also a significant increase in ischaemic heart disease (IHD) deaths on Saturdays, Sundays and Mondays. If the analysis is performed separately according to place of death, the day of the week effect is strengthened for cardiovascular deaths outside of hospital; consistent with the idea of a sudden cardiac death.

Conclusion The increase in mortality from cardiovascular diseases observed at the weekend in Lithuania is similar to that observed in Moscow and other populations. The relationship with alcohol consumption is supported by the available physiological evidence. We propose that bingeing can be solely responsible for, or acts as a ‘catalyst’ for, pathophysiological events by increasing blood pressure, cardiac rhythm and coagulability. The increased IHD mortality observed throughout the weekend and on Monday in Lithuania may reflect the influence of alcohol consumption patterns in a population already subject to high psychosocial stress.

Keywords Alcohol, cardiovascular disease, Lithuania, binge drinking

Accepted 17 July 2000


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
Lithuania, one of the three Baltic States and a former republic of the Soviet Union, has experienced similar trends in mortality during the last two decades to those observed in Russia, albeit to a lesser degree. In other words, following a long period of stagnation and even decrease for men, life expectancy rose in the mid-1980s during the Gorbatchov anti-alcohol campaign and then started to decrease again. This process accelerated in the early 1990s when life expectancy at birth fell to 63 years for men and 75 years for women. Afterwards, life expectancy started to rise again and it is now above its 1986 level for women but remains 2 years lower for men (Figure 1Go). Research in Russia has shown that these dramatic variations in life expectancy were driven mostly by variation in mortality amongst young adults.1 Between 1984 and 1987, the period of Gorbatchov's anti-alcohol campaign, mortality decreased mostly among young men but mortality increased between 1988 and 1994 for people aged between 20 and 60.



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Figure 1 Life expectancy at birth in Lithuania, in years

 
These sharp temporal variations in the death rates and demographic characteristics of those most at risk point to an acute effect of alcohol on cardiovascular mortality. To test this hypothesis we previously analysed daily variations in numbers of deaths in Moscow. This showed higher numbers of deaths from accidents and violence and alcohol poisoning at the weekend. In addition there was a significant increase in ischaemic heart (IHD) deaths among men in the Russian capital at the weekend.2


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
In this paper we repeat the analysis for the entire country of Lithuania. Computerized death certificates were analysed according to the day of death, place of death, and cause of death for the years 1988–1997. For these variables there were no missing values.

Cause of death was coded according to the Soviet Classification of Diseases, which consists of 175 categories for 1988–1992. For the years 1993–1997 the International Classification of Diseases, Ninth Revision (ICD-9) was used. A table of equivalence is given in the Appendix. Analysis was undertaken using SPSS for those dying aged 20–59 years; the age group that experienced the largest increase in mortality during transition.


    Results
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
Table 1Go presents the total number of deaths observed in Lithuania between 1988 and 1997 by cause and day of death. Deaths from accidents and violence and deaths from alcohol poisoning follow a weekly pattern with a higher number of deaths during the weekend (Table 1Go). The septadian distribution of deaths from cardiovascular diseases shows higher numbers on Saturdays, Sundays and also Mondays than during the other days of the week. This is statistically significant for men (P < 0.001). For women, although not statistically significant, a higher proportion of deaths from cardiovascular disease is also observed at the weekend and on Mondays. A similar, strengthened, pattern is observed if only IHD deaths are considered. For cancer, for which there is no suggestion of an acute effect of alcohol, there is no evidence of a daily pattern. Likewise, deaths from all other causes do not differ according to day of the week.


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Table 1 Daily variation in deaths in Lithuania, 1988–1997
 
The analysis by 10-year age groups for IHD is shown in Table 2Go. For men of all ages a higher number of deaths can be observed on Saturday, Sunday, and Monday. For women the numbers are very small in the younger age groups, however, there seems to be a tendency towards higher numbers on Sunday, and Monday for the 50–59 age group.


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Table 2 Daily variation in ischaemic heart disease deaths by age and gender
 
The ratio of incidence of deaths on Saturday, Sunday, and Monday versus the other days of the week is shown along with confidence intervals. For men, these ratios show that there is a statistically significant increase in IHD mortality during these three days for the 20–29, 40–49 and 50–59 age groups, varying between 8% and 60% excess deaths. For women, only those in highest age group (50–59 years) show a statistically significant 11% increase in mortality.

In Lithuania, as in Russia, disaggregating the IHD data into finer categories shows that the most commonly used classifications are Soviet 92 and 93 which are the codes for coronary atherosclerosis (414.0 in ICD-9).3 We found that this category is primarily responsible for the observed weekend effect (data not shown). From 1993, ICD-9 was used in Lithuania, but rarely at the four-digit level.

Similarly to data from Moscow, if the analysis is performed separately according to place of death, the day of the week effect is strengthened for cardiovascular deaths outside of hospital, which is consistent with the idea of a sudden cardiac death.


    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
The data and methodology used in this research have several limitations. First, we did not have access to autopsy reports or hospital case notes to validate the diagnosis and time of death. Second, there was a change in the disease classification system when Lithuania adopted the ICD-9 codes in 1993. However, we have identified no important discontinuities or sharp variations in the data we have used.

The third limitation concerns the inability to link individual data on deaths to individual alcohol consumption patterns. Unfortunately this level of information is unavailable in Lithuania, as in most countries of the world. As a proxy measure we are able to show from our data that deaths from alcohol poisoning and accidents/violence are significantly higher over the weekend, suggesting that a binge drinking culture exists in this country. Moreover, it is also virtually impossible to assess the contribution of alcohol to each individual death, as can be done in Finland.4 One reason for this is the relatively low rate of autopsy in Lithuania: 63.5% for men and 52.7% for women who died of IHD in the age group 20–59 years for the entire study period. However, the corresponding rates for autopsy in the case of accidents and violence were over 98% for both men and women and for alcohol poisoning nearly 100% for both sexes in this age group. For further confirmation of the relationship between cardiovascular disease deaths and binge drinking we would require access to case notes, autopsy records and possibly interviews with family members.

What information we have on alcohol consumption in Lithuania is consistent our with hypothesis. Although the officially reported level of alcohol consumption was around 9.5 l of pure alcohol per person in 1995,5 it has been estimated that up to 60–65% of the alcoholic beverage market was illegally produced or imported in 1994.6 The official estimates of alcohol consumption do not show a large increase in the early 1990s. However, it is likely that the illegal market grew enormously in those years.

Although surveys should be able to provide a more accurate estimation of alcohol consumption, they are also subject to serious underreporting.7 Lithuania is part of the FINBALT Health Monitor, a collaborative system for monitoring health behaviour in Estonia, Finland, Latvia, and Lithuania. The 1998 report for Lithuania shows a very low rate of abstention; for example only 6.7% of men and 12.4% of women reported never drinking spirits.8 Unfortunately, it was not possible to obtain total alcohol consumption from this survey, nor information on drinking patterns.

The NORBALT 1994 survey also asked about drinking habits in Lithuania. Once again, total alcohol consumption is not reported nor is pattern of drinking. However, nearly 82% of men interviewed reported drinking during the previous month. More interestingly perhaps, it shows that in the younger age groups there is a tendency towards a greater similarity of behaviour between men and women.9

A WHO sponsored survey shows that alcohol consumption amongst those who reported drinking was estimated at 25 g/day for men and 8 g/day for women. Although likely to be an underestimate, and limited by high non-response (26%), this is equivalent to a weekly consumption of at least 7 500-ml bottles of beer for men.10 Unfortunately, this dataset does not provide any information on the pattern of drinking. However, consuming 6 500-ml bottles of beer in one drinking session has been linked to a sevenfold increase in the risk of sudden cardiac death compared to drinking the same amount over several days.11

It is a well-documented phenomenon that moderate alcohol consumption is associated with a reduced risk of cardiovascular disease12 and it may therefore seem paradoxical that we are suggesting that the increased risk observed at weekends in Lithuania may be due to alcohol intake. However, both heavier drinking at the weekend and the pattern of intake might explain our observations. There is evidence, both epidemiological and physiological, to support the theory that heavy, irregular drinking may increase the risk of cardiovascular events as opposed to the protective effect of regular moderate intake.

In a recent systematic review of the published literature,13 studies that looked at pattern of drinking, either directly or indirectly, using indicators such as frequency of hangovers or reports of the consequences of drunkenness, have consistently found an elevated risk of cardiovascular death, particularly sudden death. The findings from the epidemiological research are supported by evidence that the physiological effects of regular moderate drinking and binge drinking are markedly different.14 In binge drinkers, the cardioprotective changes in high-density lipoproteins are not seen, and adverse changes in low-density lipoproteins are acquired. Chronic alcohol consumption seems capable of predisposing the heart to arrhythmia's, both by reducing the threshold for ventricular fibrillation and by causing scarring of the myocardium.15,16 The myocardium may be especially sensitive during withdrawal, as will occur after weekend binges. In addition, irregular drinking is associated with an increased risk of thrombosis, which is most likely to occur after cessation of heavy drinking.17 These physiological mechanisms may explain why we observed an increase in cardiovascular events during the weekend and on Mondays.

These findings are comparable to those obtained in Moscow. In particular, the extensive use of the code for coronary atherosclerosis in the Lithuanian dataset was also observed in the earlier analysis in Moscow. This classification was found to be largely responsible for the observed weekend effects in both countries. It is rarely used in the West, for example, comparing Moscow and London for the years 1993–1995 and the age group 20–59 years, shows that while only 13.5% of IHD deaths are recorded under coronary atherosclerosis (ICD-9 414.0) in London, 62.4% of IHD deaths in Moscow were recorded under the Soviet equivalent (92 and 93 categories).18 We previously hypothesized that these two Soviet categories were used to describe a different disease process from that understood in the West and we suspect that this category includes a range of ischaemic conditions for which there are plausible mechanisms for an acute effect of alcohol.

Our results are also in agreement with a recent study of mortality in Scotland that showed an increase in coronary heart disease deaths on Monday. Similar to our analysis on place of death, the Scottish data showed the weekend effect to be more pronounced for coronary heart deaths outside of hospital (among patients with no previous admission for coronary heart disease).19 Unfortunately, the authors did not subdivide coronary heart disease (ICD-9 410–414) into finer categories.

The Monday peak in coronary heart disease has previously been described in Germany. Willich et al. showed a Monday peak for onset of coronary heart disease (defined by chest pain) that was more apparent amongst the working population than the non-working population. However, it is not clear whether this reflects a real difference in activity or a difference in age or other risk factors. It is likely that the working population was younger, with a different set of risk factors, including maybe a higher tendency to drink excessively at the weekend.20

Bilora et al. also described a Monday increase in acute myocardial infarction among the working population (not controlled for age). The authors suggest that factors such as stress at the thought of going back to work could be involved.21 The role of alcohol in this case is more difficult to imagine because Italian drinking is characterized by regular drinking throughout the week. However, it is plausible that more drinking occurs at the weekend: a recent survey reveals that young Italians in particular do drink more heavily at weekends, and therefore we cannot rule out the possible involvement of alcohol (‘in a great majority of cases consumption is confined to Saturday nights or to the extended weekend...’22).

Further corroborative data are found in a Norwegian study in which unfavourable biochemical cardiovascular risk profiles were consistently more commonly found on Mondays than other days of the week. The authors suggest that the increased thrombogenecity (as shown by decreased levels of tissue plasminogen activator, increased plasminogen activator inhibitor and ß-thromboglobulin) may reflect a weekend-related lifestyle.23 Alcohol consumption could be one of part of this weekend lifestyle.

Similarly, examining patterns of drinking and variations in blood pressure by day of examination amongst 7735 men, Wannamathee and Shaper found higher systolic and diastolic blood pressure levels and higher prevalence of hypertension on Monday than on other weekdays.24

The Monday increase in acute IHD described in these various studies seems to be an exacerbation of the well described circadian distribution of acute myocardial infarction.25,26 This seems to be particularly clear from an Italian study showing that most of the Monday increase is due to a much higher early morning peak.27 The concept of ‘triggering’ of coronary thrombosis26,28 seems to be particularly relevant here. Under this theory, physical activity or mental stress can trigger plaque rupture by increased shear forces in the area of stenosis, disruption of the pattern of blood flow (higher coronary blood pressure, increased heart rhythm), while coagulability increase or vasoconstriction triggers occlusion by thrombus.

We argue that bingeing acts as a ‘catalyst’ on these pathophysiological events by increasing blood pressure, cardiac rhythm and coagulability.14 Under this assumption, the increased IHD mortality observed throughout the weekend and on Monday in Lithuania partly reflects the influence of alcohol consumption during the weekend in a population already subject to high pyschosocial stress.


    Conclusion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
Our research differs from most other studies on circadian and septadian distribution of IHD since we can only report on mortality, as opposed to onset of disease. However, we describe increased mortality throughout the weekend and on Monday, indicating that something taking place at the weekend is interfering with the distribution reported in other studies. We argue that high alcohol consumption can be solely responsible for, or catalyse the triggering of coronary thrombosis by modification of haemodynamic constants and/or increased coagulability of the blood.

This has implications for policy makers in Lithuania: the population should be made aware of the added cardiovascular risks of binge drinking. Moreover, our results may substantially underestimate the contribution of binge drinking to cardiovascular deaths since the number of alcohol poisonings during the week show that binge drinking is definitely not restricted to the weekend. The danger of binge drinking should also be more clearly set out in the West where it is the norm in many Anglo-Saxon countries, in particular amongst younger people.

A small research study, aiming at estimating alcohol consumption before acute IHD onset could have important implications for prevention.


KEY MESSAGES

  • A high proportion of cardiovascular deaths are reported at weekends and on Mondays in Lithuania.
  • This correlates closely with a high proportion of alcohol-related deaths.
  • This paper suggests that heavy alcohol consumption at weekends may be partly responsible for the daily variation in cardiovascular deaths.
  • Previous epidemiological and physiological evidence supports the relationship between acute alcohol consumption and cardiovascular diseases.
  • The dangers associated with binge drinking should be clearly set out in any public health strategy aiming at reducing alcohol-related harm.

 


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Appendix Classification of causes of death
 

    Acknowledgments
 
This research was funded through a grant from the Department for International Development's Know How Fund. However, DFID can not accept any responsibility for any information provided or views expressed.


    References
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
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