9. STATE OF HEALTH AND SELECTED PARAMETERS OF DEMOGRAPHIC AND HEALTH STATISTICS

9.1 Monitoring the population’s health status

The monitoring of the population’s health status is based on a questionnaire survey titled the HELEN Study – Health, Life Style and Environment. In the years 1998–2002, in the first stage the HELEN Study was carried out in a total of 27 cities in the Czech Republic. In the year 2004 began the second stage of the survey. The same methodology has been applied in a repeated survey in nine cities participating in the System of Monitoring (Brno, České Budějovice, Hradec Králové, Karviná, Kladno, Most, Olomouc, Plzeň, and Žďár nad Sázavou). In this chapter there are evaluated preliminary results from the second stage of the survey that shall be finished in 2005.

9.1.1 Structure of the questionnaire and organization of the survey

The structure of the questionnaire was designed in 1998 (first stage of the survey), in the second stage it has been supplemented with questions concerning locomotor activity and questions on dietary habits have been altered. The questionnaire consisted of 70 questions and was divided into the following sections:

In each city, through a systematic random selection ensuring the sample to be representative, there have been selected 800 subjects (400 males and 400 females) aged 45–54 years. As support for the systematic random selection there served the population register. First, the selected subjects received an informing letter, and then an investigator contacted them. The investigator handed them the questionnaire, informed them of the importance of the survey, collected the questionnaires and checked that they were fully completed. The major task of each investigator was to establish contact and convince the selected person to participate; the investigator was neither allowed to participate in the filling in the questionnaire nor to influence the respondent. The investigators were from the staff of Public Health Institutes or from Regional Public Health Authorities, as well as students of healthcare schools. The investigators received written instructions on how to proceed, and underwent unified training.

The survey also included a medical check-up to which half of the selected subjects (200 males and 200 females) were invited. The examination took place at the Public Health Institutes and was organized by their staff. The examination included repeated taking of blood pressure, body height and mass, waist and hip circumferences, and the determination of total blood cholesterol.

9.1.2 Methods of questionnaire data processing

The data obtained were processed as a whole and then separately for each city and gender. The results of the investigation are described using relative frequencies. The hypothesis on the concordance of the percentage share of the investigational categories in the contingence table was tested using the c2-test of independence. The tests were performed at the level of significance p = 0.05. The value p < 0.001 signifies a statistically significant difference between males and females, or between the individual cities.

9.1.3 Selected results – HELEN 2004

Respondency rate and structure of the series:

Health status:

Incidence of risk factors for chronic non-infectious diseases (A review of the risk factors followed up is presented in Fig. 9.1e):

Nutrition and dietary habits:

Psycho-social factors:

9.2 Selected indicators of demographic and health statistics

Within the framework of a regular presentation of selected demographic and health indicators there have been updated data on the incidence of tumor diseases. Evaluated have been developments over the period of 1979 through 2002, the present situation and trends in the Czech Republic, as well as a comparison with other countries of EU 25. Data on the Czech Republic1 have been supplied by the Institute of Health Information and Statistics from the National Oncological Register of the Czech Republic2. Data from the database GLOBOCAN 2002 have been used for comparison of tumor incidence in Europe. Tumor diseases affect foremost the elderly, and therefore, it is necessary to eliminate the influence of age distribution with the aid of the method of direct standardization (ASR – age standardized rate). The data have been standardized following the European standard; data obtained from GLOBOCAN following the world standard.

The International Classification of Diseases (ICD-10) differentiates malignant neoplasms (Dg. C00–C97), in situ neoplasms (Dg. D00–D09), and neoplasms of uncertain or unknown behavior (Dg. D37–D48). The evaluation is focused on the incidence and mortality rate due to malignant neoplasms (further only as MN), and on neoplasms in situ. The most frequently diagnosed carcinoma in males as well as in females is “other MN of the skin” (Dg. C44). In view of the low fatality rate of that MN, its frequent multiple occurrence and reappearance, it has been eliminated from the following evaluation. Moreover, the mode of reporting that diagnosis varies in different countries. To have an idea, in the Czech Republic in 2002 there have been reported 7,246 cases in males and 6,664 in females.


1 Data on proportion of death due to of MN have been taken from the database GLOBOCAN 2002.
2 Data on the occurrence of neoplasms are reported to the National Oncological Registry that in the collection of information applies the principle of their tracking down, verification, and multiple checking, wherefore definite data are available only after a two-year delay.

9.2.1 Malignant neoplasms in the Czech Republic

The incidence of selected MN and in situ neoplasms in the Czech Republic over the years 1985 through 2002 (Fig. 9.2a) has an unfavorable tendency, i.e. a persistent increase in standardized rates. In view of improved diagnostics and treatment, the increasing incidence rate is not being followed by increasing intensity of MN mortality (Fig. 9.2b). Incidence rate of MN and in situ neoplasms (ASR) over the whole period was higher in males than in females. In the year 2002 more than 50,000 new cases of MN disease (Dg. C44 excluded) and in situ neoplasms have been reported (25,305 cases in males; 25,310 cases in females).

Not counting Dg. C44, the most frequent MN in males are colorectal neoplasms (Dg. C18–C21), followed by neoplasms of the trachea, bronchus and lung (Dg. C33–C34), and MN of the prostate (Dg. C61). While the numbers of colorectal MN and prostate MN are ever on the increase, there has been a moderate drop in the numbers of cases of bronchial, tracheal, and pulmonary MN in recent years. In the year 2002, there have been reported more than 4,700 new cases of colorectal MN, more than 4,500 cases of pulmonary MN, and almost 3,400 MN of the prostate gland.

In females the most frequent are MN of the breast, the incidence of which is steadily rising. In the year 2002 there have been reported almost 5,400 new cases. Other numerous diseases include MN of the female genital organs (Dg. C51–C58). In the year 2002 more than 4,300 cases of such MN have been reported. The most frequent of them are MN of the uterine corpus (38 %), ovarian MN (29 %), and MN of the uterine cervix (25 %). Just as in males, colorectal MN are a frequent diagnosis in females, namely around 3,300 cases in the year 2002.

Malignant neoplasms belong to the most serious diseases, and in Czechia they are the second most frequent cause of death. Their share in overall mortality is increasing (Fig. 9.2b). In the year 2002, MN were the cause of death in more than 29 % of all deaths in males and almost 24 % in females. Males most often died of bronchial, tracheal, and pulmonary MN (Dg. C33, C34). These diagnoses made up over 28 % of MN deaths. That was followed by deaths due to MN of the colon and of the rectum (Dg. C18–C21) and deaths due to MN of the prostate (Dg. C61), representing 16 % and 8 % of all MN deaths, respectively. In females the most frequent cause of death due to MN was MN of the breast and MN of the colon and rectum. Each of those diagnoses made up more than 15 % of deaths in females due to MN. For details see Fig. 9.2c and 9.2d.

Fig. 9.3a and 9.3b depict the differentiation by districts of the occurrence of malignant disease in 1999 through 2002. The influence of age distribution on the incidence rate of MN was eliminated by the method of direct standardization. In both genders the highest degree of incidence of MN was in the districts of Plzeň Region, the Region Prague, and district Chomutov. On the other hand, the lowest MN incidence rate, as regards females, was in the majority of districts of the regions Hradec Králové, Zlín, Moravian-Silesian, South Moravian, and of the Region Vysočina. In males there can be traced no such regional trend in the lowest numbers of reported cases of MN. In the interpretation of results it has to be kept in mind that the incidence value is not governed only by the actual incidence of malignant neoplasms, but also by the quality and level of reporting in each of the territorial units.

Incidence of MN of the colon and rectum (Dg. C18–C21)

Over the whole period of follow-up (1979 through 2002) there has been observed an increase in the incidence of MN of the colon and rectum in males as well as in females. The incidence of that MN was also the second most frequent of the diagnostic units in both genders. Their mean values increased over the four-year periods under follow-up in males from 47.4 (1979–1982) to 88.7 (1999–2002) and in females from 37.6 (1979–1982) to 61.3 (1999–2002), see Figs. 9.4a and 9.4b. The seriousness of that disease is confirmed by the fact that these MN are up front not only in incidence but also in specific mortality rate.

Dietetic factors play the most significant role in the appearance of colon MN, namely food rich in meat and poor in fiber. On the other hand, a protective effect was found in cereals, fruit, and vegetables. A positive family history increases the risk of colorectal carcinoma. To a greater degree are threatened people suffering chronic inflammatory affections, e.g. Crohn’s disease, proctocolitis (the risk increases with increasing duration of the disorder). Likewise, a higher risk of colorectal carcinoma has been observed in certain vocations. Under higher risk are workers in cement works, in plants producing polypropylane, halogens, organic solvents, and dyes.

Incidence of MN of the trachea, bronchus and lung (Dg. C33–C34)

In all the four-year periods of 1979 through 2002 under follow-up, in the Czech Republic there has been registered a moderate decline in the incidence of those MN in males, whereas there has been a moderate rise in incidence in the case of females. Nevertheless, pulmonary and tracheal MN in males remained the most frequent diagnostic cause, its incidence in the period 1999–2002 exceeding 3.5 times that found in females. It can be expected that as regards this those diagnoses, their incidence and mortality rate in females shall rise. Elderly females that are most threatened by these kinds of MN, shall be joined by generations of females more widely addicted to the cigarette smoking habit.

In over 90 % of pulmonary tumors the cause is tobacco smoking. Smokers consuming more than 20 cigarettes a day for more than 20 years are under 20 times greater risk of acquiring bronchogenic carcinoma than non-smokers (risk limit of 200,000 cigarettes). Acknowledged are also the effects of passive smoking. This etiological factor is typical of small-cell carcinoma (19–35 %) characterized by great proliferative activity and very early metastasizing (at time of diagnosis two thirds of patients already have distant metastases). In profession-linked exposure, heavy metals (arsenic, nickel), asbestos and radioactivity appear as pulmonary carcinogens. Other carcinogenic factors include chemical compounds (polycyclic aromatic hydrocarbons, nitrosamines, mycotoxins) and viruses (RNA, retroviruses). Genetic predisposition also plays a certain role.

Incidence of malignant melanoma of the skin (Dg. C43)

From available data it follows that the mean incidence figure of malignant melanoma of the skin in the Czech Republic has had a rising trend in the course of the separate periods, and its value rose from 5.5 to 11.6 in males, and from 5.7 to 13.8 in females.

Malignant tumors of the skin are basicellular and spinocellular carcinomas. Basalioma, the most frequent dermal tumor in the 6th through 8th decennia of life, oridinates foremost due to chronic sunning. Spinocellular carcinoma (spinalioma) usually comes as a late consequence of solar radiation, effects of tobacco, or X-rays. It sometimes appears in consequence of chronic inflammatory alterations. Persons exposed to hydrocarbons in working with paraffin, mineral oils, etc. are also threatened with the appearance of a malignant dermal tumor.

Incidence of MN of the breast in females (Dg. C50)

Malignant neoplasia of the breast belongs to the most frequent and most serious in females. Over the period under follow-up there has been observed a steady rise in the frequency of this diagnosis in the Czech Republic. The mean incidence of this MN has risen from the value of 54.7 to 97.1 newly reported cases per 100,000 females. That value was also the highest found incidence out of the diagnostic units under follow-up. A positive phenomenon is the long-term stagnation in the number of deaths due to this disease. That is probably in consequence of preventive campaigns of early diagnosis of this neoplasm.

A higher incidence of MN of the breast was found in females having a positive family history regarding the mother or sister. A predisposing risk factor are certain affections in the breast, e.g. proliferative mastopathy with third degree of dysplasia, carcinoma of the contralateral mammary gland, fibroadenoma. Obesity and diet containing increased amounts of animal fats are considered to be a proven dietary risk factor for the appearing of MN of the breast. Females with early onset of menarche (before the 12th year of age), late menopause, infertile females, or those that give birth to their first child after their 30th year of age have a higher risk of appearance of breast carcinoma. At higher risk are also females suffering tumors of the uterus, ovaries, or colon.

Incidence of MN of the prostate (Dg. C61)

The mean value of prostate MN incidence in the Czech Republic over the given period has more than doubled from 25.7 (mean in 1979–1982) to 60.5 (mean in 1999–2002). Prostate MN is the third most frequent tumor in males, its incidence increasing with age.

Risk factors are not known practically. Epidemiological surveys that have studied factors of sexual behavior, excessive intake of fats, venereal diseases, etc. have not demonstrated any correlation with the incidence of the tumor. Hormone dependence, i.e. the stimulating effect of testosterone on growth of the tumor cells is present in about 80 % of all carcinomas. A relatively high incidence of prostate MN has been observed in profession-linked exposure of males to cadmium oxide.

9.2.2 Comparison of MN incidence in the countries of EU 25

In the year 2002, in the countries of present-day EU (EU 25) there have been estimated 1.1 million new cases of malignant neoplasia (excluding Dg. C44) in males, and more than 0.9 million new cases in females. In that same year, in the EU countries there have died 650 thousands of males and 500 thousands of females due to malignant neoplasm. The incidence is higher in males in all countries of the EU.

The highest incidence of MN (Dg. C00–C97, excepting Dg. C44), standardized by age, has been in the case of males in Hungary, and in the case of females in Denmark. On the other hand, the lowest incidence for both genders was in Greece, Latvia, and Cyprus. The incidence in males and in females in Czechia exceeds the mean of the EU 25 countries (Fig. 9.5a).

Incidence of MN of the colon and rectum in males in European countries likewise exceeds that in females. The incidence rate (ASR) of those MN is depicted in Fig. 9.5b. Frequent is the occurance of colorectal MN in males in central Europe in Czechia, Hungary, and Slovakia. In females, besides in mentioned Hungary and Czechia, an above-average incidence is also in Denmark and Germany.

The incidence of MN of the trachea, bronchus and lung in males in Czechia, just as in the EU 25 countries, has decreased negligibly while the numbers of new cases in females are continuously increasing. The highest incidence rate (ASR) was in Hungary, Poland, and Belgium (in males), and in Denmark, Great Britain and Ireland (in females) (details in Fig. 9.5c). The high incidence rate is considered to be connected, foremost, with the consumption of tobacco products.

The incidence rate (ASR) of malignant melanoma of the skin, in contrast to previously named MN is not greater in males. Out of the EU 25 countries the incidence rate of this MN was greater in males only in the case of Finland, Italy, Hungary, Czechia, Slovakia, and Slovenia. The highest values in the incidence rate of Dg. C43 have been reached in Sweden and Denmark (in both genders). The lowest were in Greece, Cyprus, and Latvia; and in males in Lithuania (details in Fig. 9.5d). The incidence rate of this diagnosis in Czech females is around the mean in the EU 25 while in males it exceeds the mean.

The incidence of MN of the breast represents the highest values out of the malignant neoplasms in females analyzed in Czechia and other European countries. Among the countries in which there has been the highest incidence of this MN in 2002 were Belgium, France, Denmark (Fig. 9.5e). The lowest values were found in the Baltic Republics. The incidence (ASR) of MN of the breast in Czechia in 2002 was 58.4, being thus below the mean in the European countries under follow-up.

Malignant neoplasia of the prostate in certain countries of the EU 25, in 2002, represented the greatest numbers of new cases of malignant neoplasm in males. Among the countries where the incidence of prostate MN is the highest of MN in males, are Sweden, Finland, Austria, Germany, Great Britain, Ireland, Cyprus, France, and Portugal. Countries with the highest value of incidence are Sweden and Finland (details in Fig. 9.5f). The lowest values, on the other hand, have been attained in Latvia, Poland, and Greece. Czechia with 38.1 is below the EU 25 mean.

9.3 Partial conclusions

A half of the urban population aged 45–54 years, under follow-up rated their health as good, almost 13 % as poor. Long-term health complaints (treated or not) suffers more than half of the population of the age group under follow-up, most frequently concerning the locomotor apparatus and cardiovascular diseases. While there was no significant difference between males and females in the occurrence of long-term health complaints, females took medicines on a long-term basis significantly more frequently than males. The most frequently occurring diseases were those of the spine and joints, being reported by more than a third of the respondents, and high blood pressure that was found in more than a quarter of them.

There were almost 20 % obese subjects, i.e. with a serious risk factor of cardiovascular disease, in the age group 45–54 years under follow-up. About 35 % of male respondents were active tobacco smokers; female smokers among the respondents less by 4 %. In some cities, however, the difference between the genders was negligible. There were found significant differences between cities in the numbers of smokers – the most being in Karviná, Most, and Kladno; the least being in Brno, Hradec Králové, and Žďár nad Sázavou. A significant proportion of females, almost a quarter of them, consumes less liquids than is the recommended daily intake; females abiding by most of the other principles of rational nutrition more frequently than males. There have been found significant differences between cities in the excessive consumption of alcohol. The greatest consumption being found in Kladno, and the lowest in Žďár nad Sázavou. In almost two thirds of the respondents there has been found a low level of purposeful physical exercise.

In the age group of 45–54 years, 52 % of respondents were in principle satisfied with their lives. While the respondents in individual cities did not doffer in their overall satisfaction with their lives, they differed significantly in the rating of the social and living environments in individual cities.

Malignant neoplasms are the second most frequent cause of death in Czechia. The mortality rate of MN is stagnant, however, the share of MN in total deaths is increasing. The incidence rate (ASR) of MN in Czechia is increasing continuously. The ncidence rate in males in Czechia is higher in all the diagnoses under follow-up than in females, including namely as regards malignant melanoma of the skin. In males the most frequently reported are new cases of MN of the colon and rectum, MN of the bronchus, trachea and lung, and MN of the prostate. In females the most frequently reported are new cases of MN of the breast, MN of the genital organs, and MN of the colon and rectum. Czechia has attained higher values of total incidence rate of MN than the European (EU 25) average. Out of the diagnoses under follow-up the Czechia has attained more favorable values than other EU countries in the case of MN of the breast and MN of the prostate; on the other hand, Czechia has attained outright “primacy” in the case of colorectal MN.

Fig. 9.1a Subjectively perceived health status in the last six months
Fig. 9.1b Personal medical history, long-time health complaints
Fig. 9.1c Personal medical history, diseases notified by physician
Fig. 9.1d Prevalence of selected diseases
Fig. 9.1e Risk factors of chronic non-infectious diseases
Fig. 9.1f Prevalence of regular smoking
Fig. 9.1g Environment quality evaluation in neighbourhood
Fig. 9.1h Annoying environmental factors in neighbourhood
Fig. 9.2a Incidence of neoplasms in CZ, 1985–2002
(ICD-10, Dg. C00–C97 and D00–D09, Dg. C44 excluded)
Fig. 9.2b Mortality due to malignant neoplasms in CZ, 1985–2002
(ICD-10, Dg. C00–C97)
Fig. 9.2c Proportion of deaths due to malignant neoplasms in CZ, males, 2002
(ICD-10, C00–C97, Dg. C44 excluded)
Fig. 9.2d Proportion of deaths due to malignant neoplasms in CZ, females, 2002
(ICD-10, C00–C97, Dg. C44 excluded)
Fig. 9.3a Incidence rate (ASR) of neoplasms in districts of CZ, males (average over years 1999–2002)
(ICD-10, Dg. C00–C97 and D00–D09, Dg. C44 excluded)
Fig. 9.3b Incidence rate (ASR) of neoplasms in districts of CZ, females (average over years 1999–2002)
(ICD-10, Dg. C00–C97 and D00–D09, Dg. C44 excluded)
Fig. 9.4a Incidence of selected malignant neoplasms in CZ (1979–2002), males
Fig. 9.4b Incidence of selected malignant neoplasms in CZ (1979–2002), females
Fig. 9.5a Age standardized incidence rate of malignant neoplasms in EU states, 2002
(ICD-10, Dg. C00–C97, Dg. C44 excluded)
Fig. 9.5b Age standardized incidence rate of malignant neoplasm of colon and rectum in EU states, 2002
(ICD-10, Dg. C18–C20)
Fig. 9.5c Age standardized incidence rate of malignant neoplasm of trachea, bronchus and lung in EU states, 2002
(ICD-10, Dg. C33–C34)
Fig. 9.5d Age standardized incidence rate of malignant neoplasm of skin in EU states, 2002
(ICD-10, Dg. C43)
Fig. 9.5e Age standardized incidence rate of malignant neoplasm of breast in EU states, 2002
(ICD-10, Dg. C50)
Fig. 9.5f Age standardized incidence rate of malignant neoplasm of the prostate in EU states, 2002
(ICD-10, Dg. C61)

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