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Major Causes of Death in China
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     To the Editor: The epidemiologic analysis of deaths in China by He et al. (Sept. 15 issue)1 suggests a change in pattern toward that in Western societies: heart disease, cancer, and cerebrovascular disease are now listed as the top three causes of death. However, respiratory diseases are clearly underrepresented in their report, because of the way the causes of death were classified. The conclusions of the authors may perpetuate the chronic underrecognition of lung diseases and lessen the pressure on governments to promote their prevention and management. Simply acknowledging (in the legend to Figure 1 of the article) that "chronic pulmonary heart disease . . . is usually caused by chronic obstructive pulmonary disease " is insufficient. Those who read the article will focus on heart disease, cancer, and stroke, because these are what the authors conclude are the major causes of death.

    We challenge the authors to reanalyze their data and present total mortality from COPD, asthma, pulmonary infections (including tuberculosis), other less common lung diseases, and lung cancer (because of its close relationship to smoking and COPD). We believe that, if the causes of death were properly classified, a picture would emerge showing that lung diseases as defined here are at least as important a public health target as heart disease, cancer, and stroke.

    Peter D. Wagner, M.D.

    American Thoracic Society

    New York, NY 10006

    pdwagner@ucsd.edu

    Giovanni Viegi, M.D.

    European Respiratory Society

    1003 Lausanne, Switzerland

    Carlos M. Luna, M.D.

    Asociación Latinoamericana del Tórax

    1828 Buenos Aires, Argentina

    Yoshinosuke Fukuchi, M.D.

    Asian Pacific Society of Respirology

    Tokyo 113-0033, Japan

    Paul A. Kvale, M.D.

    American College of Chest Physicians

    Northbrook, IL 60062

    Asma El Sony, M.D., Ph.D.

    International Union against Tuberculosis and Lung Disease

    75006 Paris, France

    References

    He J, Gu D, Wu X, et al. Major causes of death among men and women in China. N Engl J Med 2005;353:1124-1134.

    To the Editor: In the study by He et al., overweight or obesity, as compared with normal weight, was not associated with increased mortality. This finding is inconsistent with the growing literature indicating that obesity is a major risk factor for cardiovascular diseases, type 2 diabetes, stroke, and certain types of cancer as well as death from all causes. However, other data indicate that obesity is positively related to socioeconomic status in China.1 Higher socioeconomic status is associated with better access to health care, better nutrition, and less depression. Low socioeconomic status is well known to be a powerful predictor of all-cause mortality, as shown in many previous studies.2,3 Further analysis of the associations among socioeconomic status, obesity, and mortality in the data of He et al. may clarify this issue.

    Ming Wei, M.D.

    Kun Wang, M.D.

    9 Columbia Dr.

    Camp Hill, PA 17011

    References

    Xu F, Yin XM, Zhang M, Leslie E, Ware R, Owen N. Family average income and body mass index above the healthy weight range among urban and rural residents in regional Mainland China. Public Health Nutr 2005;8:47-51.

    Lynch JW, Kaplan GA, Cohen RD, et al. Childhood and adult socioeconomic status as predictors of mortality in Finland. Lancet 1994;343:524-527.

    Wei M, Valdez RA, Mitchell BD, Haffner SM, Stern MP, Hazuda HP. Migration status, socioeconomic status, and mortality rates in Mexican Americans and non-Hispanic whites: the San Antonio Heart Study. Ann Epidemiol 1996;6:307-313.

    To the Editor: He and colleagues assessed physical activity by categorizing the physical labor involved in a participant's work. Other data indicate that other types of physical activity are important to consider with regard to Chinese persons. First, in other studies, cycling and a combination of walking and riding buses were the most common means of transportation, and less than 10 percent of adults reported an absence of physical activity during commuting in urban China.1,2 Second, housework, as one of the daily physical activities of adult women, accounted for 50 percent of the overall physical activity among adult women.3 Third, traditional Chinese tai chi, or morning exercises, was commonly practiced by many Chinese adults and elderly persons.4 Previous studies in China showed no reduction in the risk of cardiovascular disease in association with heavy physical activity related to occupation, whereas the risk of colon cancer was inversely related to commuting-related physical activities and mortality was reduced with greater leisure-time physical activity.1,2,3,4

    Bin Wang, Ph.D.

    Nanjing Medical University

    Nanjing 210029, China

    binwang@njmu.edu.cn

    References

    Hu G, Pekkarinen H, Hanninen O, et al. Physical activity during leisure and commuting in Tianjin, China. Bull World Health Organ 2002;80:933-938.

    Hou L, Ji BT, Blair A, Dai Q, Gao YT, Chow WH. Commuting physical activity and risk of colon cancer in Shanghai, China. Am J Epidemiol 2004;160:860-867.

    Ma J, Liu Z, Ling W. Physical activity, diet and cardiovascular disease risks in Chinese women. Public Health Nutr 2003;6:139-146.

    Lam TH, Ho SY, Hedley AJ, Mak KH, Leung GM. Leisure time physical activity and mortality in Hong Kong: case-control study of all adult deaths in 1998. Ann Epidemiol 2004;14:391-398.

    To the Editor: The analysis of mortality in China by He and colleagues includes more than 1000 deaths per 100,000 person-years in China due to respiratory causes (infections and COPD). The sole risk factor for respiratory illness that they examined was a history of cigarette smoking (defined as smoking at least one cigarette per day for one or more years). Solid-fuel use has been linked to respiratory diseases, including COPD, and in the case of coal, to lung cancer.1 In Guangdong province, a recent survey showed that only 10.9 percent of women with COPD had ever smoked, but solid-fuel use was a significant risk factor.2

    The World Health Organization has estimated that 80 percent of Chinese households use biomass fuel, with coal used in 31 percent of households. The attributable mortality of solid-fuel use in the Western Pacific region (primarily China) has been estimated to be more than half a million lives.3 Exposure to solid-fuel use is an important preventable contributor to mortality that was not addressed in an otherwise fine study. The limitation of exposure to biomass combustion should be added to the list of preventive measures.

    V. Theodore Barnett, M.D.

    Medical College of Wisconsin

    Milwaukee, WI 53226

    tbarnett@mail.mcw.edu

    References

    Bruce N, Perez-Padilla R, Albalak R. The health effects of indoor air pollution exposure in developing countries. Geneva: World Health Organization, 2002. (WHO/SDE/OEH/02.05.)

    Liu SM, Wang XP, Wang DL, et al. Epidemiologic analysis of COPD in Guangdong Province. Zhonghua Yi Xue Za Zhi 2005;85:747-752.

    Desai MA, Mehta S, Smith KR. Indoor smoke from solid fuels: assessing the environmental burden of disease at national and local levels. WHO environmental burden of disease series. No. 4. Geneva: World Health Organization, 2004.

    The authors reply: Wagner and colleagues correctly point out that chronic pulmonary heart disease can be classified as either respiratory disease or cardiovascular disease. In our study, the causes of death were coded according to the International Classification of Diseases, 9th Revision (ICD-9).1 Respiratory disease would be a leading cause of death in China if chronic pulmonary heart disease were included in that category (Table 1). Dr. Barnett suggests that solid-fuel use is an important risk factor for COPD, besides cigarette smoking, in China. Unfortunately, data on solid-fuel use were not collected in our study.

    Table 1. Age-Standardized Mortality Associated with Respiratory Disease.

    As indicated by Drs. Wei and K. Wang, socioeconomic status and access to health care are important potential confounders of the association between body-mass index and mortality from all causes. In addition, hypertension and diabetes are key intermediate factors in the causal pathway between body-mass index and mortality.2 Without adjustment for hypertension and diabetes, we found that obesity was associated with increased mortality from all causes (relative risk of death, 1.20; 95 percent confidence interval, 1.08 to 1.30) among urban residents but not among rural residents (relative risk, 0.90, 95 percent confidence interval, 0.73 to 1.19). In our study, only work-related physical activity was measured at the baseline examination. We agree with Dr. B. Wang that other forms of physical activity are important in China. Lack of data on leisure-time physical activity was identified as a limitation of our study.

    Jiang He, M.D., Ph.D.

    Tulane University

    New Orleans, LA 70112

    jhe@tulane.edu

    Dongfeng Gu, M.D.

    Chinese Academy of Medical Sciences

    Beijing 100037, China

    Paul K. Whelton, M.D.

    Tulane University

    New Orleans, LA 70112

    References

    International classification of diseases, 9th rev., clinical modification: ICD-9-CM. Los Angles: Practice Management Information Corporation, 1998.

    Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality among women. N Engl J Med 1995;333:677-685.