The study’s central innovation is methodological. Rather than relying on mortality rates alone, which can be misleading when disease prevalence differs sharply between countries and sexes, the team calculated the mortality-to-prevalence ratio, or MPR, dividing the age-standardised mortality rate by the age-standardised prevalence rate. Because ischaemic heart disease is a chronic condition, the population at risk of dying includes both newly diagnosed patients and the millions living with established disease, making prevalence a more appropriate denominator than incidence. A high MPR signals that, relative to the number of people living with the disease, deaths are excessive, a pattern that often points to weaknesses in prevention, treatment or both. The researchers also normalised risk-attributable mortality by prevalence to construct a case-fatality index, or CFI, which asks whether deaths attributable to a specific risk factor, such as tobacco or high blood pressure, are high or low among those actually living with the disease.

The headline numbers show genuine progress. Between 2011 and 2023, age-standardised mortality from ischaemic heart disease fell across the region in both sexes, with relative reductions of 2.6 percent in men and 3.7 percent in women, and regional mean MPRs declined from 5.32 percent to 4.32 percent in men and from 5.84 percent to 4.48 percent in women. Yet the averages conceal extraordinary heterogeneity. In 2023, mortality rates among men ranged from 216.93 per 100,000 in Hungary and 210.50 in Bulgaria down to just 63.55 in Slovenia, with women showing a parallel spread from 158.62 in Serbia to 29.17 in Slovenia. Slovenia’s case-fatality levels were statistically indistinguishable from those of the six founding members of the European Union, demonstrating that Western European outcomes are achievable within the region.

When the researchers applied formal Z-score testing to sex differences in MPR, a clear geography of inequality emerged. In 2011, women had significantly worse outcomes in Croatia, Serbia, Czechia and Bosnia and Herzegovina, while men fared worse in Poland and Bulgaria. By 2023, the disparities had narrowed but persisted in Croatia, Serbia and Czechia, with Z-scores of 5.55, 2.55 and 2.18 respectively, while Poland showed a significant reversal, with men now experiencing the higher mortality burden relative to prevalence. In Croatia and Serbia, women’s case-fatality was 46 percent and 38 percent higher than men’s, respectively. More modest but still meaningful female disadvantages appeared in Slovakia, Montenegro, North Macedonia and Bosnia and Herzegovina, whereas Bulgaria and Poland were the only countries where women-to-men ratios fell below one.

What drives these divergent patterns? The analysis points to two opposing domains of risk. In most countries, women exhibited higher case-fatality indices than men for the major metabolic risks, including elevated systolic blood pressure, fasting plasma glucose, LDL cholesterol and body mass index, with Croatia, Serbia and Slovakia showing the most pronounced female disadvantage, exceeding 20 percent for all four. Physical inactivity exerted a proportionally far greater impact on women, particularly in the Balkans, where the female-to-male CFI ratio reached 4.57 in Croatia and 4.11 in Serbia. Tobacco, by contrast, remained an overwhelmingly male hazard, with Albania’s tobacco-attributable male burden nearly six times that of women. In countries such as Croatia and Serbia, the female disadvantage domain of inactivity, metabolic vulnerability and dietary deficits predominates, while in Poland the absence of a strong female disadvantage leaves the universal male hazard from tobacco unopposed, helping to explain the reversal of the sex gap there.

Diet emerged as a critical and underappreciated component of the female disadvantage. Because dietary estimates carry wide uncertainty intervals, the team used Slovenia, the country with the lowest case-fatality, as an empirical benchmark, a choice validated by the finding that Slovenia’s MPR is statistically comparable to those of Belgium, France, Germany, Italy, Luxembourg and the Netherlands. This benchmarking revealed significant sex differences for seven dietary risks: low intake of whole grains, fruits, nuts and seeds, vegetables, seafood omega-3 fatty acids and fibre, along with high sodium intake. Low intake of nuts and seeds was the only dietary factor consistently associated with a significant female disadvantage in all three high-disparity countries, Croatia, Serbia and Czechia, suggesting a shared and potentially tractable population-level pattern. Country-specific deficits added further risk, most notably low fruit and vegetable intake in Croatia and low omega-3 intake in Romania, while male-specific dietary excesses were confined to isolated exposures such as high sodium in Romania and low whole grains in Bulgaria.

The biological plausibility of these dietary effects is well supported. Low intake of fruit, vegetables, nuts, seeds and omega-3-rich foods has been linked to higher blood pressure, impaired vascular function, inflammation and adverse cardiometabolic profiles, and these foods are foundational to the Mediterranean, DASH and Nordic dietary patterns with strong outcome evidence. The authors also point to possible physiological amplification in women, noting that the menopausal transition, with declining oestrogen levels, is associated with adverse lipid changes and vascular dysfunction that may heighten the impact of inadequate intake of omega-3-rich foods and micronutrient-dense sources such as nuts and seeds. Weight-promoting medications, including certain antidepressants, beta-blockers and insulin, may further compound cardiometabolic risk in midlife and older women, although medication use was not directly assessed in this ecological analysis.

Socioeconomic forces appear to compound these physiological vulnerabilities in a structural paradox: women with heart disease may experience relative deprivation of protective foods despite potentially greater nutritional needs. Croatia, though a high-income country, maintains one of the highest at-risk-of-poverty rates in the European Union at 21.7 percent, while upper-middle-income Serbia shows similarly high social vulnerability at 24.3 percent. Food insecurity, unequal household food allocation, gendered norms influencing food selection and time poverty from unequal domestic and caregiving responsibilities may all restrict women’s consistent access to nutrient-dense foods. Czechia offers a contrasting case, where excess female risk emerges despite low poverty levels of roughly 9.5 percent, suggesting that even a comparatively modest additional female shortfall in nuts and seeds, within a population-wide deficit of whole grains and fibre, may be sufficient to produce measurable sex differences in case-fatality.

Health-system capacity alone does not explain the patterns either. The researchers examined coronary revascularisation rates relative to disease prevalence and found that a country’s procedural capacity does not predict its pattern of sex disparity. Croatia and Bulgaria had among the highest procedure-to-prevalence ratios in the region, yet Croatia exhibited a significant disparity disadvantaging women while Bulgaria showed near-identical case-fatality between the sexes. This indicates that equitable outcomes depend not only on system capacity but on the fairness of clinical pathways determining who receives treatment. The findings align with individual-level data: Poland’s male disadvantage corresponds with registry evidence of higher sudden out-of-hospital cardiac arrest in men, while Serbia’s female disadvantage is consistent with Belgrade coronary care data showing higher in-hospital mortality in women with ST-elevation myocardial infarction even after adjustment for age and comorbidities.

The authors are careful to note the limitations of their approach. The analysis relies on modelled GBD estimates rather than primary clinical datasets, its ecological design precludes causal inference at the individual level, and the mortality and prevalence inputs of the MPR are structurally interrelated within the GBD modelling framework, meaning the ratio should be interpreted as a comparative indicator rather than a direct survival estimate. Nevertheless, the message for policymakers is clear: declining mortality does not automatically translate into equitable survival. The researchers call for cardiovascular surveillance systems to complement traditional mortality statistics with sex-specific, prevalence-adjusted indicators, and for a dual-track prevention strategy that confronts the pervasive male tobacco epidemic while addressing the female triad of physical inactivity, poor diet and metabolic risk. Slovenia demonstrates that low case-fatality is achievable in the region; the task now is to translate that benchmark into targeted, sex-sensitive action in the countries where preventable risks continue to drive excess deaths.

Subject of Research: Sex differences in ischaemic heart disease case-fatality and their dietary and lifestyle determinants across Central Europe

Article Title: Contributions of diet and lifestyle to sex differences in ischaemic heart disease burden in Central Europe: an analysis of the Global Burden of Disease Study 2023

Article References: Bugiardini, R., Rahaman, T., Badimon, L., Cenko, E., Anand, S. S., Manfrini, O., Merkely, B., Milicic, D., Townsend, N., Vaccarino, V., Gulati, M., & Gale, C. P. (2026). Contributions of diet and lifestyle to sex differences in ischaemic heart disease burden in Central Europe: an analysis of the Global Burden of Disease Study 2023. The Lancet Regional Health – Europe, 70, Article 101846. https://doi.org/10.1016/j.lanepe.2026.101846

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101846

Keywords: ischaemic heart disease, Global Burden of Disease, Central Europe, sex disparities, case-fatality, dietary risk factors, physical inactivity, tobacco, hypertension, mortality-to-prevalence ratio, cardiovascular prevention, nutrition policy

The central finding is chronological. Millet, the researchers discovered, was already being consumed in southeastern Poland around 1590 BCE, more than a century earlier than previous estimates had suggested. That revision matters because the timing of millet’s arrival has long been debated among European archaeologists. The crop, domesticated originally in what is now Inner Mongolia, spread westward along trade and contact networks that connected the steppe with the settled farming societies of Europe. Knowing precisely when it appeared in local diets allows archaeologists to align that arrival with broader developments in Bronze Age society, including population growth, increasing food demand and shifting climatic conditions.

Equally significant is the manner of the adoption. The isotope data show that millet did not sweep through the region as an instant staple. Instead, it was consumed at first by only a handful of individuals, gradually working its way into foodways that had been dominated for millennia by wheat and barley. By analysing tissues that form at different stages of life, the team could reconstruct dietary change within individual lifetimes. Several early millet consumers had clearly grown up eating the traditional cereals, only incorporating the new grain later in adulthood. This within-lifetime evidence pins down the moment the crop entered existing diets with a precision that conventional archaeological methods rarely achieve.

The multi-proxy approach at the heart of the study is what makes such fine-grained conclusions possible. Carbon and nitrogen isotope ratios in bone collagen reflect a person’s average diet over the years, capturing the relative contribution of different plant and animal foods. Oxygen and strontium isotopes, by contrast, record the geology and hydrology of the places where an individual’s food was produced during tissue formation. Radiocarbon dating anchors the timeline, palaeoproteomic analysis of tooth proteins establishes biological sex, and previously published ancient genetic data situates individuals within the region’s population history. Each line of evidence answers a different question, and only by reading them together could the researchers distinguish local dietary change from the arrival of new people.

That distinction proved crucial. Both millet consumers and non-consumers in the study shared broadly similar archaeological and genetic backgrounds, and the earliest consumers carried strontium isotope signatures compatible with local origins. The data therefore offer little support for a simple migration-based explanation, in which the crop would have arrived with an incoming population that brought its own farming traditions. Instead, the evidence points to an innovation adopted from within, by communities already rooted in the region, in response to pressures and opportunities they faced in their own environment.

The environmental dimension of the story is where the study’s implications expand beyond diet. Broomcorn millet grows quickly, matures within a single summer season, and tolerates relatively dry conditions and poor soils far better than wheat or barley. Those qualities meant that cultivating it opened up parts of the landscape that had previously seen little agricultural use. According to the researchers, the different strontium isotope compositions found in the skeletal tissues of millet consumers compared with non-consumers likely point to the use of distinct geological zones within the same territory, rather than to different places of birth. In other words, the crop’s adopters were farming different ground.

Lead author Dr Depaermentier of Vilnius University frames the shift as a deliberate strategy. In response to increasing food demand and potential changes in climatic conditions, Bronze Age societies adopted a new resilient staple crop to optimise the use of previously marginal parts of their environment and improve food security. The phrase captures a logic that will feel familiar to modern agricultural planners: diversify the crop base, exploit underused land, and buffer the community against the risk of harvest failure. What the isotope evidence adds is proof that this logic was already operating in European prehistory, centuries before written records could document it.

Just as striking is what the study reveals about who adopted the crop. Millet consumption was not restricted to any particular sex, age group or social status, as co-author Prof Makarowicz of Adam Mickiewicz University in Poznań observes. Together with the strontium isotope evidence, this pattern indicates that access to particular parts of the landscape, rather than social identity, was the determining factor shaping who ate the new grain. The division between consumers and non-consumers mapped onto geography, not hierarchy. Senior author Prof Motuzaitė Matuzevičiūtė, also of Vilnius University and principal investigator of the ERC-CoG MILWAYS project, notes that the study is the first to link such a division of the landscape to the cultivation of a new summer crop and to the exploitation of areas that had previously seen little agricultural use.

That conclusion reframes how archaeologists think about prehistoric innovation. The spread of new crops is often narrated in terms of diffusion, trade or conquest, as if ideas and technologies simply travelled across maps. This study instead documents adoption as a local, negotiated process, unfolding over generations, unevenly distributed across a society, and driven by the practical realities of soil, water and subsistence. A handful of individuals began eating a new grain; their communities learned to grow it on land their ancestors had left uncultivated; and over time the practice spread until the crop became a staple. No single dramatic event marks the transition, yet the cumulative result was a fundamentally different relationship between people and their environment.

The findings also carry a contemporary resonance. As modern agriculture confronts climate change, water scarcity and degrading soils, crop diversification has returned to the centre of policy discussions, and researchers increasingly look to the past for evidence of how societies have managed similar challenges. The Bronze Age farmers of southeastern Poland offer a case study in successful adaptation: they identified a crop suited to marginal conditions, integrated it gradually into existing systems, and used it to expand production without abandoning their traditional cereals. Understanding how such transitions succeeded in prehistory, the authors suggest, can inform current debates about building resilient food systems. A grain that travelled from Inner Mongolia to the Carpathian foothills three and a half thousand years ago turns out to have lessons that still speak to the present.

Subject of Research: The adoption of broomcorn millet and its impact on Bronze Age land use in Central Europe

Article Title: The adoption of a new crop reshaped land use in Bronze Age Europe

Article References: The adoption of a new crop reshaped land use in Bronze Age Europe. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: broomcorn millet, Bronze Age, Central Europe, isotope analysis, bioarchaeology, land use, food security, paleodiet, strontium isotopes, crop adoption, Science Advances, southeastern Poland