Radio/ Oncol 1994; 28: 40-8. 

Risk factors connected with the appearance of chronical diseases and cancer in the Republic of Slovenia 
Dražigost Pokorn 
University of Ljubljana, Medica! Faculty, Institute of Hygiene, Slovenia 
The article shows the most frequent risk factors in the Republic of Slovenia that the author could gather on the basis of available sources in Slovenia. We could conclude that relatively high incidence and prevalence of chronical and degenerative diseases (cardiovascular diseases and cancer) in the Republic of Slovenia or their permanent increase, if compared with western countries, where it is lower and decreasing already for severa! years, is a consequence of a much too intensive presence of risk factors in the Republic of Slovenia. Only after a change in the policy of nutrition, environmental protection, medica! education and a changed medica! welfare service in general, it will be possible to decrease the incidency of these diseases in the newly established s tate of Slovenia. 


Key words: neoplasms-epidemiology; chronic disease-epidemiology; risk factors; Slovenia 
Introduction 


With their endeavours to prolong the life expec­tancy (Table 1) during the last twenty years the Slovenians stayed considerably behind their neighbouring countries. In Slovenia, the main reasons for premature mortality are the same as in other European countries; undoubtedly Slovenia is one of the countries where its inha­bitants loose their lives because of injuries and suicides. 1 Slovene patients with cardiovascular diseases and cancer, representing 69 .1 % of ali causes of death, are dying earlier as similar patients in the neighbouring countries. Since 1970, mortality from ischaemic heart diseases has been growing in Slo_venia similarly as in other countries of Central and Eastern Europe, while the trend in the developed countries of Northern Europe2 is opposite (Figure 1). Du­ring the last few years a slight decrease in premature mortality from heart-and coronary 
3 

diseases can be observed (Figure 2). 1• Cancer incidence (1950-1987) is also growing (Figure 3).4 The Slovenians contract these diseases be­cause of worse primary prevention, consequen-

Table l. Lifge expectancy in 5 European eountries, 
1 1970, 1980, 1988.

Country  1970 1980 1988  
Men Women Men Women Men Women  
Corespondence to: Prof. Dražigost Pokorn,  PhD, MD, Austria  66.3 73.4 69.0 76.1 72.1 78.7  
Instit ute of Hygiene, Medica! Faculty, 61000 Ljubljana, Slovenia.  Zaloška 4, Germany Italy Sweden  67.2 73.6 69.6 76.8 72.3 79.1 68.6 74.7 71.0 77.6 72.7 79.2 72.3 77.4 72.8 79.0 74.2 80.4  
UDC: 616-006.6-036.2-02  Slovenia  65.0 72.3 67.4 75.2 67.6 76.8  



/C.echoslovakia Finland 
UK 
-Bulgaria 
Slovenia 
France 
-Spain 
1970 1975 1980 1985 Year 

Figure l. Premature mortality from ishaemic heart diseases. Standard mortality rate for men and women, 0-64 years of age, per 100 000.1• 2 

1985 1986 1987 1988 1989 1990 e ar s 
Y 

Figure 2. Premature mortality from cardiovascular (CVD) and ishaemic heart diseases (IHD) in Slovenia. Standard mortality rate for men and women, 35-64 years of age, per 100 000.1• 3 
Rate per 100000 

tly larger prevalence of risk factors, or these illnesses are discovered later and treated less successfully. 
The main purpose of this article is to try to show the most frequent risk factors in the Republic of Slovenia on the basis of available sources in Slovenia. 
The quoted data can serve only as an orien­tation for a survey of risk factors associated with the appearance of chronical diseases in a country that has only started with the preven­tion of cardiovascular diseases and cancer. 
Material and method 

The data on dead inhabitants acording to the causes of their death, sex and hospital admis­sions due to the diseases of resident population by international classification of diseases (ICD) are based on the Medical Statistical Annual of Slovenia, 1991, published by the Institute of Health of the Republic of Slovenia, 1 collecting health statistics. From the same source we also took the data on diseases detected in specialized out-patient departments and on gastrointestinal diseases for 1969-1991 and 1977-1989. Data on age-standardized mortality for men and women· (for the age 0-64 years per 100.000 inhabitants) were specialy prepared for this survey by the Institute for Health (Personal Report 1992). We incorporated them into the figure showing mortality from ischaemic heart diseases in Cen­tral, Eastern and North Europae (E. Helsing).2 The data on annual cancer incidence, crude incidence rate per 100.000 inhabitants in the Republic of Slovenia, and on annual incidence rates of stomach cancer were obtained from the Central Cancer Register of Slovenia at the Institute of Oncology in Ljubljana.4 Data on the production, transport and sales of food and on the annual consumption of food and bevera­ges per household member for 1965-1988 and 1970-1990 were derived from the Statistical Annual of the Republic of Slovenia, which is published regularly by the Statistical Office of the Republic of Slovenia.5 
The energetic value of an average daily meal and the nutrient ratio: protein, fats, carbohy­
sumption of food and beverages per household member in the Republic of Slovenia according to the inquiry on the consumption in house­holds, performed by the Statistical Office of the Republic of Slovenia for 1965-1988 and 1970­1990 every five years,5 and by the help of plates with nutritional values of the food, Zagreb 1990.6 In 1988 the pattern of a five-year inquiry included 3.250 households: 56 rural, 811 mixed and 2.383 nonrural households, chosen accor­ding to the method of random selection. 
The Statistical Office of the Republic of Slovenia was also the source of data on the production of cigarettes. Data on the emission of sulphur dioxide into the air by consumers of fuel and raw materials in the Republic of Slove­nia are -on the basis of analyses made by the Institute for Hydrometeorology of the Republic of Slovenia5 -also gathered by the Statistical Office of Slovenia. 
The analyses of samples of drinking water as to their bacteriological and chemical irreproac­habilty are regularly performed by regional institutes of hygiene and social medicine in the 
Republic of Slovenia. Data on irreproachability of drinkable water were obtained from the Report ·of these microbiological laboratories.1 The analysis of the magnesium content of drin­kable water in Slovenia in 79 at random chosen water sources ( of open and closed type) was in 1981 and 1982 performed by the Center for Mineral Water Research in Maribor, Republic of Slovenia. 7 
The data on individual risk factors (smoking, obesity, hypertension, hypercholesterolemia) were obtained from the !atest epidemiologic reasearches in Slovenia: Berger et al,8 Accetto and Javornik;9 Pokorn;10 Srebot et al;11 Fortic12 and Strgar;13 Gradišek et al;14 Jezeršek et al;15 Radisavljevic et al. 16 
The daily nutritional pattern and the content of salt and dietary fibrins in the daily food pattern of the older population was taken from the study of Pokorn et al. 17 
It is interesting that although chronical diseases affect different organic systems and differ com­pletely also as to their etiopathogenesis, the risk factors for some of them are very similar. For example: the development of arteriosclero­sis is advanced by numerous factors, the effects of which should not only be added-up, because they intensify each other.18 Therefore it is extre­mly difficult to explain the influence of food on heart and coronary diseases, if important risk factors for the appearance of arteriosclerosis such as physical activity and cigarette smoking of the population are not known. 
As important risk factors for the appearance of heart and coronary diseases and cancer among the population of Slovenia, we took into account some nutritional factors, alcohol abuse, and polluted environment, which are systemati­cally collected by the state institutions, and also some other available risk factors -smoking, elevated blood pressure, and plasma concentra­tion of cholesterol. 
Among the risk factors for the appearance of chronical diseases it is food that may be one 
20 
of the most important risk factors.19• With the average consumption of food and beverages per household member in the Republic of Slo­venia (1965-1988) a rise in the consumption of individual groups of food -with the exception of fats -can be observed. The variability of 
371' fat 
Sat  Carbohydrates  Protein  
.  D  Jl:'2il  
ccal/ capita/day  
1965  2539  
1970  2505  
1975  2972  
1.80 J.  2566  
1984  3288  
1985  3343  
1986  3021  
1987  2524  
1988  2312  
o 10  20  30  40  50  60  110 80  90  100 "  
J.J8'%, carbohydrate ( 6, 7'f. sucrose)  
15'%. protein  

Figure 4. The proportion of fat, carbohydrates and protein in the total energy supply in Slovenia, 1965­1988. 5 

----in 100 000 hl 

'.l 
3., 

10 . 
o_ 

Bo 
60 so-, 


vely large, which could be attributed to diffe­rent and insufficiently accurate methods of hou­seholds inquiring. 
After 1965 an obvious fall in the food con­sumption can be observed, which can be seen 
fish 

also from the average energetic and nutritional 8 
1 
in lOOOton 

value of an average daily meal (Figure 4). From 6 1965 to 1985 the energetic value of an average 5 
4 
daily meal was growing from 2539 to 3343 Kcal. Afterwards it started to fall and in 1988 it ranged at 2312 Kcal/day when an average meal 
meat 

of a Slovenian contained more than 35 % of 
20 
in 1000 ton 

fats and approximately 15 % of proteins in 
respect to the energetic value of the consumed food. The ratio between the animal and vegeta­ble fats was decreased (Table 2). The share of 
eggs 
in 1000000 


Table 2. The proportion of animal and vegetable fat in the total fat supply in Slovenia, 1979-1989.5 
pieces 

Year  Animal fat (%) Vegetable fat (%) Olive oil (5)  
1979  n  n3  0.1  
1984  .  .8  0.2  
1989  M  .-8  0.2  

olive oil, which is supposed to have also an important protective influence on the appea­rance of arteriosclerosis, 19 is extremly low. A bigger share of vegetable oils in everyday nutri­tion can be partly proved also by the increasing production of this food in the Republic of Slovenia. The increased production of eggs, meat, milk and fish during the last twenty years (Figure 5) caused a rise of the percentage of proteins in the daily nutrition and probably also 
40 30 20 10 
1970 1975 1980 1985 1990 
Y e a r s 

Figure 5. Production of protein food in Slovenia, 1970-1990.5 
The quantity of the consumed fruit and vegetables has been falling since 1979-1989 (Table 3). Because of the low quantity of daily consumed fruit and vegetables and cereal pro­ducts, especially wholegrain cereals, the content 
Sugar** Rate per capi ta 
per per year 
of saturated fats. 
100 "'-, 
,' 
/ 120 teet
110 100 --.-.._."----­
' 
/ , 
' 
­/ 
The quantity of the consumed table sugar per 

household member was falling extensively from 
21 20 19 
18 
l'1 / \ 90 sugar . 

1975 to 1988, while the quantitative trade with 
sugar and candy production are both increasing, 
17 
11' 
Bo 
1 / " 16 
V 70 

which means that the consumption of sugar products, chocolate, cakes, etc. is on the increa­se. Together with a lower consumption of table sugar there is also a fall in caries incidence (Figure 6). The cause for a lower caries rate in the Republic of Slovenia can not be found only in the lower consumption of table sugar, but also in the improved mouth hygiene and better teeth fluoridation. 21 
1965 ffJ 70 75 79 00 84 &S 00 90 
Year 

Figure 6. Treatment* in general dental clinics by HC domicile, Slovenia, 1969-1990 and available supply of 
5 

sugar in Slovenia, 1965-1988.1• 
* Teeth filling with and without treatment, surgical treatment ( extracted teeth and other treatment). 
** Sugar consumption per persona per year in Slove­nia. 
5,2 5,5 5,9 3,8 
Unit  1979 1984 1989  
Vegetables Fruit Dietary fiber  kg/day kg/year g/day  31.6 56.8 16.4  16.6 32.7 16.0  15.7 31.2 15.1  

of dietary fibers in the daily nutrition has also been decreasing -in the same period it ranged between 16.4 and 15.1 g/day. Together with a low consumption of fruit and vegetable there is also a lower consumption of protective sub­stances and this can be an important risk factor for the appearance of cardio-vascular diseases and cancer. 22-27 
An extremly low value of daily consumed fibers in the daily nutrition of Slovenian popu­lation was established also with the analysis of 56 at random chosen patterns of daily meals in the city of Ljubljana. The value of fibrins ranged between 3.5-21.9 g/day (7.7 
+ /-3.9 g/day).17 
A lot of eggs, fats, sugar, meat and milk products and a low quantity of fruit and vege­table ( dietary fibrins) can also be a risk factor 
29 
for the appearance of gallstones,28' which is also on the increase (Figure 5). 
We lack <lata on salt consumption in house­holds, but we do have <lata on the quantitative wholesale trade with food (salt). Between 1970 and 1990 the trade with salt increased strongly. An analysis of 56 daily meals showed that the daily salt content ranged between 4.6 and 16.6 g salt/day (8.7 + /-2.9 g/day), which exceeds the protective food recommendations.17, 22 
Serum levels of vitamins A and E, which are also important factors in the prevention of cardiovascular diseases and cancer, were analy­sed in 189 randomly selected and examined persons, aged over 60 years and living in Ljub­
ljana (Figure 7). We did not observe an obvious lack of these three nutrients, which could be partially proved by a menu pattern containing a relatively varied combination of fruit, vegeta­bles, cereals and milk. Approximately 90 % of the examined persons had a standardized pla­sma vitamin E, and over 30 µM/mM of chole­sterol. Only with approx. 41 % of ali examined 
6 
.! 4 
t. t. 
"'"' 3 
o. o. 2 .-; 1 
o 

1965 1970 1975 1980 85 88 
Year s 
Figure 7. The annual average alcohol (100 vol%) con­
5 sumption in Slovenia, 1965-1988.
persons the plasma vitamin A exceeded 2.1 M/1, according to Gey et all,24 this represents the normal preventive concentration of vitamin A and of the standardized vitamin E in the plasma of the examined persons. 
Because magnesium content in drinking wa­ter can, to a certain degree, also be important for the prevention of cardiovascular diseases,30 we give a substantial and up till now the only epidemiologic study of magnesium content in drinking water of the Republic of Slovenia. Among 79 randomly chosen samples of drinking water we found 20 samples of water with a low magnesium content. 
In the period 1970-1990, an increase was noted also in the field of quantitative trade with alcoholic beverages. In the period from 1965 to 1985, the quantity of consumed pure alcohol, obtained from the consumption of food in hou­seholds,5 ranged between 5.2 and 7.1 1 per year and person. Afterwards, the consumption of alcohol was steadily decreasing until in 1988 it achieved only 3.8 1 per year and person (Figure 7). Lower consumption of alcohol could be 
Mortality per 100 000 
30 25 
20 
8 
7 

10 
5 
1975 1980 
iz'.3 men 
Figure 8. Cirrhosis mortality in Slovenia, 1975-1989. 1 


Arthritis 

gure 8). This has been proved also by a less 
and 
s pondy li tis 
Cancer 

frequent appearance and hospitalization of alco­holic liver cirrhosis in the period from 1977 to 1989. 
Simultaneously with the increased production of beer we can observe a rise of rectal cancer 
(Figure 9). Although some epidemiological stu­

Ischaemic 
heart 
diseases 
Cholecystitis 
and 
Rate 

per 100000 
C holelythiasis 
Bronchitis 

18 Beer 
1 per capita 16 per year 
and 
e.mphisema 
1<m 1991 Y e a r 125 1979 

12 
100 
75 
Fram 1965 till 1984, a steep increase in 
1965 1970 25 

cigarette production is characteristic. After­wards, an obvious fall can be observed (Figure 
1980 1985 1990 
Average annual crude 

Figure 9. 
Y e ar s 11). Different studies on smoking habits of the Slovenians, performed between 1987 and 1992, 
incidence of 
rates 

known environmental pollutants, which can also 
i 

play an important role in the appearance of 
400 
chronical diseases: polluted air, drinking water, smoking of cigarettes and equipment of indivi­dual households with refrigirators, ali these are 
orientational indicators of less spoiled food 
300 
among the population. 
250 
The emission of sulphur dioxide into the air 

200t / 
by individual consumers of fuel and raw mate­rials in Slovenia had been steadily increasing 150 1 until 1987. Afterwards, it obviously began to 
100 / 1965* 


rectal cancer (male) and production of beer in Slove­
5 nia, 1965-1990.4• 

dies clearly point out a connection between consumption of beer and rectal cancer, there 
32-34 

are others which cautiously deny that.20, Causes for such a high annual incidence of rectal cancer in Slovenia could also be due to inappropriate nutrition, smoking and some ot­
32-35 

her causes.20• Our survey of risk factors includes some including more than 18.000 of inquired persons aged between 15 and 101 years, showed that up to 40 % of men and up to 29 % of adult 
women within the inquired population were smokers; among the youth aged from 15 to 17 years, there were 17.9-27.8% of smokers (boys and girls together). In comparison with other countries where smoking is already strongly restricted, having as a consequence a lower 
Index 
fall, especially due to stricter legislation measu­res. This could also be the cause for a less frequent appearance of lung diseases during the 
last years (Figure 10). 36 
70 80 Years 90 

Figure 11. Production of cigarettes in Slovenia, 1965­1991. 5 
incidence of chronical diseases, the percentage of smokers in Slovenia is still very high. 
A relatively rough indicator of hygienic irre­proachability of food is the availability of refri­girators in households. Food kept in refrigira­tors is less prone to perishing and has a lower content of nitrites which are an important factor 
38 
for the appearance of nitrosamines.37• The availability of refrigerators in households in 1978 was almost 79 % , and rose in 1988 to almost 94 % . This could be one of the reasons for a lower incidence of stomach cancer in the Republic of Slovenia. Chemical and microbi­ological pollution of our waters is still very high. 
Increased serum cholesterol is an important risk factor for the development of atherosclero­sis. Other risk factors (hypertension, smoking, diabetes, obesity, physical non-activity, beha­viour pattern) are often connected with the hypercholesterolemy, but play a minor role in the case of its absence.18 Cholesterol must achieve the value of 5 mmol/1 to cause the development of atherosclerosis. Other risk fac­tors do not play such an important role (18). Table 4 shows the rate of persons with total plasma cholesterol exceeding 5.2 mmol/1 among the total of 4695 adult subjects from 5 wide 
Table 4. Incidence of elevated plasma cholesterol levels in Slovenia (>5.2 mmol/l). 
%subjects Place of research Men Women No Age groups 
Zgornja Šcavnica (8) 79.3 76.3 1132 25-64 Brnik (8) 58.6 54.1 743 25-64 Ljubljana (14) 67.0 60.0 1692 25-64 Ljubljana (9) 47.9 67.8 696 60-94 Ljubljana* (10) 17.1 30.7 432 60-101 
* institutionalized subjects 
epidemiologic studies performed in the Repu­blic of Slovenia. The results show that more than a half of the examined subjects have an important and basic risk factor for the develop­ment of atherosclerosis -but these results can­not be generalized for the whole Slovene terri­tory. 
Six studies, published in Slovenia between 1987 and 1992, which included 8049 examined subjects (Table 5) showed that the population aged between 25 and 70 years had a relatively different prevalence of hypertension, which is also an important factor for the appearance of cardiovascular and cerebrovascular diseases. Such variability of results can also be a conse­quence of different methods for blood-pressure 
3941 
measurements. 
In five epidemiological studies which included 7572 subjects aged from 7 to 101 years we could observe excessive body weight and obesity in 
9.6 % of the examined men aged between 25 and 64 years, and 22.2-41 % of the examined women. Among children aged between 7 and 15 years there were only 2.8-4.7 % of boys and 4.8-7.7% of girls with excessive body weight (Table 6). Relatively high body weight of the subjects, although their daily energy consump­tion is relatively low, can be a consequence of insufficient physical activity and of too high a 
43 
content of fats in the daily nutrition.42• 
Conclusion 
We could conclude that a relatively high inci­dence and prevalence of chronical and degene­rative diseases in the Republic of Slovenia, or their constant increase, -if compared with western countries where it is lower and has been decreasing for several years already, -is 

Table 5. Incidence of elevated blood pressure (mm Hg) in Slovenia. 
% subjects  
Place of research  Men  Women  Together  No  Age groups  
Ljubljan. Šiška (15)  - - 18.9  2965  40-70  
Zgornja Scavnica (8)  17.6  22.9  1132  25-64  
Brnik (8)  17.0  17.1  743  25-64  
Ljubljana (14)  47.3  30.9  39.1  1692  25-64  
Ljubljana (9)  37.9  51.2  46.1  695  60-94  
Ljubljana* (10)  37.1  50.2  47.9  822  60-101  
* institutionalized subjects  

Men Women 
Ljubljana (14) BMI 49.0 41.0 897 25-64 Ljubljana (9) Q 69.9 61.9 699 60--94 Zgornja Šcavnica (8) 
Brnik (8) RTM 19.2 23.0 
Maribor (16) RTM 1033 7 1107 11 RTM 6.3 4.6 

RTM 2.8 4.8 928 15 
BMI = body mass index (kg/m2); * > 2.7 RTM = relative body mass: (% ); * > 120 Q = Quetelet's index (body mass/body height2 (g/cm2)); * > 2.57 
a consequence of a much too intensive presence of risk factors in the Republic of Slovenia. Only after a change of the policy concerning nutri­tion, environmental protection, medica! educa­tion and a changed medica! welfare service in general, it will be possible to lower the inci­dence of these diseases in Slovenia. 
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