Regional Differences in Stroke Mortality and Alcohol
Consumption in Japan
HIROTSUGU UESHIMA, M.D.,
TAKAKO OHSAKA, M.D.,
AND SHINTARO ASAKURA,
19
M.D.
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SUMMARY The relationship between alcohol consumption and stroke mortality in 1975 in 46 prefectures
of Japan was investigated. This was done by adjusting salt intake and several socio-economic factors, i.e.,
the annual per capita income, the number of persons who received public aid, the number of tatamis (a
Japanese traditional floor unit) per household, the unemployment rate, and the unmarried or divorce rate,
using a stepwise multiple regression analysis. As dependent variables, the sex-specific and age-adjusted
mortality for the middle-aged (35-59 years) and for all ages due to stroke were used. For men, alcohol
consumption was significantly related to age-adjusted stroke mortalities for the middle-aged and for all ages
independent of salt intake and several socio-economic factors. Alcohol consumption was more strongly
related to age-adjusted stroke mortality for the middle-aged than for all ages. For women alcohol was
weakly correlated with the stroke mortality of the middle-aged. Salt intake was significantly correlated with
stroke mortality for women but not for men. Furthermore, the male: female ratios of the age-adjusted
stroke mortality for the middle aged and for all ages were analyzed as well, because alcohol is mostly
consumed by men in Japan, and it was expected that the sex ratios would be well correlated to alcohol
consumption. The results were as expected. Therefore, it was suggested that the regional difference in
stroke mortality in Japan may be explained in part by that of alcohol consumption.
Stroke Vol 17, No 1, 1986
STROKE has been one of the leading causes of death
in Japan.1 Hypertension is a major risk factor for
stroke.2'8 Mortality, the incidence of stroke, and the
prevalence of hypertension have been higher in the
northeastern than in the southwestern part of Japan.
These areas with high stroke mortality and high prevalence of hypertension correspond to high salt intake.2-9"" However, alcohol intake is higher in the
northeastern part of the main island (Honshu) of Japan,
especially in Akita Prefecture, than in any other area. '2
It is well documented not only by cross-sectional epidemiological studies but also by follow-up studies that
moderate or heavy level of alcohol drinking is related
to hypertension.13"16 Furthermore, several animal and
epidemiological studies suggest that alcohol is a risk
factor for stroke independent of hypertension.6-8 l7~22
Therefore, whether or not the regional difference in
stroke mortality across 46 prefectures is related to alcohol consumption, and independent of salt and several
socio-economic factors in Japan, was analyzed by a
stepwise multiple regression analysis.
Materials and Methods
Statistics for 46 prefectures, excluding Okinawa, in
1975 were used to analyze the relationship between
stroke mortality and alcohol consumption. Age-specific stroke mortality data by prefecture and sex were
available in the Special Report of Vital Statistics in
Japan, 1975.M The age-adjusted stroke mortalities for
all ages by sex were calculated using the national population census and five-year age-specific mortality rate
in 1975.24 In this study, the age-adjusted stroke mortality for the middle-aged (35-59 years) as well as for all
ages were calculated. This is because it was observed
From the Department of Public Health, Osaka University Medical
School, 4-3-57 Nakanoshima Kita-ku, Osaka 530, Japan.
This study was supported in part by the Life Insurance Association of
Japan
Address correspondence to: Dr. Hirotsugu Ueshima, Department of
Preventive Medicine, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565, Japan.
that the decreasing rate of middle-aged men's mortality due to all causes of death slowed down in comparison with other age and sex groups,25 and because most
of the alcohol was consumed by middle-aged men.26
Furthermore, male:female ratios of age-adjusted
stroke mortality were also calculated for the middleaged and for all ages to analyze the relationship between the sex ratio and alcohol consumption. Alcohol
consumption per person per year by prefecture was
calculated from the Annual Report of the Tax Administration Agency;27 total alcohol consumption by prefecture was divided by the population aged 20 years
and over. No data on sex-specific alcohol consumption
was available. To estimate salt intake by prefecture,
data on salt excretion per creatinine (g/g) in the spot
urine of three-year-old children by prefecture was
used.28 Since it was found that the data of the salt
excretion was correlated with the salt intake recorded
in the National Nutrition Survey,28 this data seems to
reflect the variation of salt consumption by prefecture.
Several socio-economic factors for each prefecture
were used in a stepwise multiple regression analysis.
These factors were, the annual income per capita, the
number of men per 100,000 who are receiving public
aid, the number of tatamis (a Japanese traditional floor
unit) per household, the unemployment rate per
100,000 men, the unmarried rate per 100 men aged
35-49, and the annual incidence rate of divorce per
1000 persons. Data on these factors was obtained from
the Statistics on Social Life29 and the Annual Report of
Social Welfare, 1975,30 the Population Census of Japan, 197531 and Vital Statistics, 1975.32
Age-adjusted stroke mortalities for all ages and for
the middle-aged by sex, and the male:female ratio of
age-adjusted stroke mortality for the middle-aged and
all ages were used as dependent variables, while alcohol consumption, salt intake and socio-economic factors were used as independent variables in a stepwise
multiple regression analysis. The same independent
variables were used for the stepwise multiple regres-
STROKE
20
VOL
17, No
1, JANUARY-FEBRUARY
1986
TABLE 1 Mean and Standard Deviation of Stroke Morality, Alcohol Consumption, Salt Excretion, and Other Socioeconomic Variables in 46 Prefectures of Japan, 1975
Variable
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Age-adjusted stroke mortality for the middle-aged (35-59 years old)
Men (number of death per 100,000 population per year)
Women (number of death per 100,000 population per year)
Male:female ratio
Age-adjusted stroke mortality for all ages
Men (number of death per 100,000 population per year)
Women (number of death per 100,000 population per year)
Male:female ratio
Annual alcohol consumption per person aged 20 years and over
(equivalent volume to 100 ml of sake)
Number of tatamis per household
Unemployment rate (number of unemployment per 100,000 men)
Annual income per capita (1,000 Yen)
Unmarried rate (number of person per 100 men aged 35-49 years)
Annual incidence of divorce (number of divorce per 1,000 persons)
NaCl/creatinine in spot urine of three-year-old children (g/g)
Rate of receipt of public aid (number of person per 100,000 population)
Mean
SD*
81.84
43.46
1.89
18 21
6.71
0.32
124.36
111.13
1.12
19.73
15.33
0 08
508.30
27.89
100.32
972.06
3.51
0.99
18.72
102.45
88.25
5.11
40.54
163.43
1.05
0.21
3.56
56.35
*SD is standard deviation
sion analysis of both men and women. Either the unmarried rate or the divorce rate was used as an independent variable.
Results
Characteristics of the Variables
Table 1 shows the mean and standard deviations of
the variables used in this study. Stroke mortality for
middle-aged (35—59 years old) men was higher than
that for women, and the male:female ratio of it was
1.9. However, there was no large difference between
male and female stroke mortality for all ages.
Annual alcohol consumption per capita was 50,800
ml of sake — about 18g of ethanol per day. Average
excretion of salt per creatinine was 18.7 (g/g) in the
spot urine of three years old children.
Simple Correlation Analysis
The matrix of the simple correlation coefficient is
shown in table 2. Alcohol consumption correlated
highly and significantly with the stroke mortality for
middle-aged men (fig. 1) and the male:female ratio of
the stroke mortality for the middle-aged (fig. 2) and all
ages. The correlation coefficient between the age-adjusted stroke mortality for middle-aged women and
annual alcohol consumption per capita was far lower
than that for men (r = 0.322, p < 0.05).
On the other hand, salt intake correlated significantly but moderately with women's stroke mortality for
the middle-aged and for all ages and weakly with
men's stroke mortality for all ages. Salt intake correlated neither with the male:female ratio of the stroke
mortality for the middle-aged nor for all ages. There
was no correlation between alcohol consumption and
salt intake across 46 prefectures. Annual income corre-
lated significantly and negatively with 5 of 6 cases of
stroke mortality.
Figure 3 shows the geographic variations of ageadjusted stroke mortality for middle-aged men (35-59
years old) and annual alcohol consumption per capita
by quintiles and prefecture. The stroke mortality and
alcohol consumption in the north-eastern part of the
main island (Honshu) and southern island (Kyushu)
were higher than in other prefectures. Most of the prefectures belong to the top or second class of the quintiles for stroke mortality and alcohol consumption.
Since most alcohol is consumed by men in Japan,
the male:female ratio of the stroke mortality was expected to correlate with alcohol consumption. The results were as expected (fig. 2, table 2).
Stepwise Multiple Regression Analysis
The results of a stepwise multiple regression analysis showed that alcohol consumption was significantly
related to the age-adjusted stroke mortality for middleaged men and women independent of salt intake (table
3). The F value of alcohol was far lower in women than
in men. Therefore, the multiple correlation coefficient
(multiple R) was far higher in men than in women. Salt
intake was significant for the analysis of women but
not for men. For men, the number of tatamis was
significant as well.
Table 4 shows the result of the analysis on the ageadjusted stroke mortality for all ages. For men, alcohol
consumption and annual income were significant. For
women, salt intake was significantly related to the ageadjusted stroke mortality for all ages. Thus, alcohol
was significantly correlated to the male stroke mortality for all ages independent of salt intake and other
socio-economic variables.
n.
STROKE AND ALCOHOL CONSUMPTIQN/(/ej/iima et al
124
•
109
•
94
•
*
•
•
•
79
r = 0 618
o
»
p<0 001
64
n = 46
o
men aged 35-59
49
374
460
546
632
718
804
TOTAL ALCOHOL (equivalent to sake.x 100ml/capita/year)
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FIGURE 1. The correlation between age-adjusted stroke mortality for middle-aged men (35-59 years old) and annual alcohol consumption per capita in 1975. Alcohol consumption is
converted to that of sake, and the unit is 100ml per capita per
year.
Table 5 shows the results of the stepwise multiple
regression analysis of the male:female ratio for the
middle-aged and for all ages. Alcohol consumption
was significantly correlated to the sex ratio of ageadjusted stroke mortality for the middle-aged and for
all ages. The number of tatamis was significantly related to that for the middle-aged, and annual income was
significant and negatively related with that for all ages.
The same analyses were carried out using the divorce rate as an independent variable. Almost the same
results as those shown in tables 3, 4 and 5 were obtained.
Discussion
In this study, we first demonstrated that the geographic variation of stroke mortality in 1975 among 46
prefectures in Japan was significantly related to alcohol consumption which was independent of salt intake
and several socio-economic factors. Recently, several
epidemiological studies have revealed that alcohol
drinking is related to high blood pressure, although
there is controversy about the threshold effect.13"16 A
Japanese epidemiological study revealed that there
was a graded relationship between alcohol consumption and the blood pressure level; it was independent of
obesity, smoking habits, hemoglobin concentration,
serum uric acid and serum lipid levels.16 Two followup studies in Chicago, U.S.A. show that alcohol drinking induces hypertension.14 It is also reported that the
patients who stopped drinking show decreasing blood
pressure levels, while those who started to drink again
show an increase in blood pressure levels not found in
those who did not start to drink again.33 The mechanism explaining why drinking more alcohol increases
the blood pressure level or induced hypertension has
not yet been clearly delineated, although there are
some findings that the adreno-cortico and medullar
hormone system, renin-angiotensin system and vasopressin system are related to alcohol ingestion.34"38
Several follow-up studies on stroke risk factors reveal that alcohol drinking is a risk factor in
stroke.6-8 18~22-39 It is reported that alcohol concentration which parallels that needed for its graded effects
of euphoria, mental haziness, muscular incoordination, stupor and coma in humans induces graded contractile responses in rat cerebral arterioles and venules
in vivo and in isolated canine basillar and middle cerebral arteries.17 Thus, alcohol ingestion may play a role
in causing stroke by increasing blood pressure and
contracting cerebral arteries.
The people who are living in the northeastern part of
the main island of Japan where the consumption of
sake is high also have a high consumption of salt10- "
and engage in manual farm labor. Such factors as high
STROKE MORTALITY
ALCOHOL CONSUMPTION
(men aged 35-59,
(.SaJse.,100 ml per c a p i t a
per 100.000 persons/year)
/year)
•1571W 84.1-950
i771-830
19
S53I661- 770
CZ] -66.0
~~. ) 531-570
! "" 468-530
5:555 431-467
I
|
-430
«
1.6
13
374
460
546
632
718
804
TOTAL ALCOHOL (equivalent to sake, xlOO ml/capita/year)
FIGURE 2. The correlation between the male'female ratio of
age-adjusted stroke mortality for middle-aged (35-59 years
old) and annual alcohol consumption per capita. Alcohol consumption is converted to that of sake, and the unit is 100ml per
capita per year.
FIGURE 3. The age-adjusted stroke mortality for middle-aged
men (35-59 years old) and the annual alcohol consumption per
capita by prefecture and quint Hes in 1975. Alcohol consumption
is converted to that o/sake, and the unit is 100ml per capita per
STROKE
22
VOL 17, No
1, JANUARY-FEBRUARY
1986
TABLE 2 Matrix Showing the Simple Correlation of Alcohol Consumption, Salt Intake and Selected Socio-economic Variables in 46
Prefectures of Japan, 1975
Stroke mortality for
the middle-aged
Male:
female
Men
Women
ratio
Stroke mortality for all ages
Men
Women
Male:
female
ratio
Alcohol
0.584*
-0.042
-0.399t
0.079
0.248
0 286
- 0 085
0.117
0.007
-0.283*
-0.189
0 335*
0.465*
0 094
0 322*
Salt
Income
-0.361*
0.315*
-0.206
-0.159
-0.301*
-0.121
-0.400t
-0.133
-0.242
0.594*
0.233
Stroke mortality for
the middle-aged
men
women
male • female ratio
Stroke mortality for
all ages
men
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women
male:female ratio
Alcohol
Salt
Income
Tatamis
Unemployment
Public aid
Unmarried rate
Divorce rate
0.609*
0.719*
0.888*
0.669*
0.670*
0.618*
0.274
-0.427t
0.219
0006
0.163
-0.050
0.011
-0.109
0.614*
0.662*
0.109
0.322*
0.295*
-0.266
0.008
- 0 101
0004
-0.044
-0.049
0.571*
0.253
0.749*
0.509*
0.095
-0.315*
0.253
0.123
0.230
-0.019
-0.070
0.895*
0 480*
0.359*
0.360*
-0.444t
0.432t
-0.247
-0.102
-0.198
-0.246
0.043
0.123
0 442t
-0.315*
0.448t
-0.397t
-0.252
-0.195
- 0 339*
*p < 0.05, to < 0.01, tp < 0.001.
salt intake and hard manual labor may be confounding
factors. Salt was significantly related to stroke mortality for women in a multiple regression analysis. Since
it seems that men and women have the same tendency
of salt intake when salt intake in 46 prefectures is
compared, salt may relate to stroke mortality for men
as well. As a matter of fact, the simple correlation
coefficient between salt and male stroke mortality for
all ages was significant.
TABLE 3 Stepwise Multiple Regression Analysis* ofAge-adjusted
Stroke Mortality for the Middle-aged (35-59 years) in 46 Prefectures, Using the Independent Variables of Alcohol Consumption,
Salt Intake, Annual per Capita Income, Unemployment Rate, Rate
of Receipt of Public Aid, Number o/Tatamis (Japanese traditional
floor unit) and Rate of Unmarried Men
Variable
Standardized
coefficient
F value
Significance
Men
Alcohol
Tatamis
Salt
Women
Alcohol
Salt
0.672
38 495
0.290
6.474
0.178
2511
Multiple R = 0.726
p < 0.001
p < 0 05
0.320
5.419
0.293
4.545
Multiple R = 0 435
p < 0.05
p < 0.05
NS
•Selection criteria is F = 2.0.
Variables are listed in order when they are included in the equation.
In Japan, in contrast to Europe and North America,
few women drink alcoholic beverages, although recently the number who drink beer or whiskey has been
increasing. A national survey shows that only 3 percent of females drink alcoholic beverages every day,
compared with 47 percent of males.26 If those who
drink sometimes are included in addition to those who
drink every day, the rate for women is still only 21
percent, while that for men is 74 percent. Therefore,
men contribute the most to the consumption of alcoholic beverages, and this has resulted in higher simple and
multiple correlation coefficients between alcohol consumption and stroke mortality in men than in women.
It has also resulted in high simple and multiple correlation coefficients between alcohol consumption and
male:female ratios of stroke mortality. Alcohol consumption was weakly but significantly correlated to
stroke mortality in middle-aged women, however this
might be induced by possible confounding factors.
Since data was not available on women's alcohol consumption by prefecture, we could not conclusively
state whether or not alcohol consumption explains,
even in part, the regional differences in stroke mortality of women as well.
For the analysis of age-adjusted stroke mortality for
the middle-aged, the coefficients of alcohol were far
higher than for those of all ages. One of the possible
reasons is that there is a difference in the alcohol drinking pattern between the middle-age group and all age
groups, i.e., few people under age 20 in Japan drink
publically, and the rate of drinkers over 70 years old is
23
STROKE AND ALCOHOL CONSUMPTION/(/w/i/ma et al
TABLE 2 (continued)
Tatamis
Unemployment
Public
aid
Unmarried
rate
Divorce
rate
TABLE 5 Stepwise Multiple Regression Analysis* of the Male '•
Female Ratio of Age-adjusted Stroke Mortality for the Middle Aged
(35-59 years) and for All Ages in 46 Prefectures, Using the Independent Variables of Alcohol Consumption, Salt Intake, Annual
Income per Capita, Unemployment Rale, Rate of Receipt of Public
Aid, Number o/Tatamis (Japanese traditionalfloorunit), and Rate
of Unmarried Men
Variable
The Middle-Aged
Alcohol
Tatamis
Unmarried men
Unemployment
All Ages
Alcohol
Income
Standardized
coefficient
F value
Significance
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18.343
0.525
14.238
0.646
3.510
0.276
2.741
0.240
Multiple R = 0.674
p < 0.001
p < 0.001
NS
NS
0.512
17.318
-0.255
4.278
Multiple R = 0.633
p < 0.001
p < 0.05
•Selection criteria is F = 2.0.
Variables are listed in order when they are entered in equation.
0.529$
0.383t
0.600*
0.493*
0.893*
0.176
0.594*
0 .088
0 .515*
0441t
lower than that of drinkers in the 30-69 years age
group.26
The number of tatamis was significantly related to
stroke mortality in 2 of 6 analyses. Since relatively
large houses in Japan tend to be farm houses located in
the country-side, as compared with the small houses
TABLE 4 Stepwise Multiple Regression Analysis* ofAge-adjusted
Stroke Mortality for All Ages in 46 Prefectures, Using the Independent Variables ofAlcohol Consumption, Salt Intake, Annual per
Capita Income, Unemployment Rate, Rate of Receipt of Public Aid,
Number o/Tatamis (Japanese traditional floor unit), and Rate of
Unmarried Men
Variable
Standardized
coefficient
F value
Significance
Men
Income
Unemployment
Alcohol
Tatamis
Unmarried men
Women
Tatamis
Salt
Alcohol
Unemployment
found in cities, this does not mean that rich people or
prefectures with relatively large houses is a risk factor
in stroke. The result shows rather that people who are
living in poor prefectures with large farm houses have
a high stroke mortality rate. The annual income was
weakly and negatively related to the stroke mortality
for men of all ages and the male: female ratio of stroke
mortality for all ages. Prefectures with low annual
income seem to have many factors that increase stroke
mortality.
This study does not show how alcohol was related to
stroke risk on an individual base. That the relationship
between stroke and the alcohol drinking habit should
be investigated further by case-control and/or prospective follow-up studies, addressing both the acute and
chronic effects of alcohol drinking. The impact of alcohol drinking on stroke may be strong if the relationship between them is real because the alcohol drinking
habit is prevalent in industrialized societies.
Acknowledgments
5.197
-0.380
-0.285
3.557
8 972
0.390
0.355
4.029
2.341
0.254
Multiple R = 0.694
0.248
2.809
0.302
5.477
4.212
0.266
-0.293
3.815
Multiple R = 0.627
p < 0.05
NS
p < 0.01
We wish to thank Prof. Masashi Okamoto for his advice on the
statistics, although he is in no way responsible for the statistical presentation in this paper. Also, we wish to thank Mr. Yasuo Katsuki for his
technical assistance.
NS
NS
NS
p < 0.05
NS
NS
•Selection criteria is F = 2.0.
Variables are listed in order when they are included in the equation.
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Regional differences in stroke mortality and alcohol consumption in Japan.
H Ueshima, T Ohsaka and S Asakura
Stroke. 1986;17:19-24
doi: 10.1161/01.STR.17.1.19
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