Vitale Gesellschaft Health and disease in Germany, Europe and worldwide: Facts, predictions and chances for prevention U

1. Vitale Gesellschaft Health and disease in Germany, Europe and worldwide: Facts, predictions and chances for prevention Ulrich Keil Institut für Epidemiologie und Sozialmedizin der Universität Münster WHO Collaborating Centre for Epidemiology and Preventionof Cardiovascular and Other Chronic Diseases

2. According to the UN the world population reached6 billion on October 12, 1999. 1804 1 billion people 1926 2 billion people 1960 3 billion people 1999 6 billion people prognosis for 2050 9 billion people 122 years 34 years 39 years Growing of the world population

5. Source: Statistisches Bundesamt, Bundesinstitut für Bevölkerungsstudien

6. Population of Germany by age groups1950–1998 Source: Statistisches Bundesamt

8. 77.0 EU average Germany 74.6 Europe years Source: WHO – European health for all database (HFA-DB) – www.who.dk/hfadb * 1997 Life expectancy at birth for men in Europe 1991 and 1998

9. 82.7 EU average Germany 80.8 Europe years Source: WHO – European health for all database (HFA-DB) – www.who.dk/hfadb * 1997 Life expectancy at birth for women in Europe 1991 and 1998

10. Contribution to gap in life expectancy between central and eastern Europe andrest of European region for men and women by age and cause of death in 1992 Figures are difference in years between West minus East Source: Bobak, M and Marmot, M. East-West mortality divide and its potential explanations. BMJ 1996; 312: 421–25

12. Change in rank order of leading causes of death (world) 2020* Disease or injury 1990 Disease or injury * baseline scenarios Source: Murray CJL, Lopez AD. The Global Burden of Disease. Cambridge: Harvard University Press, 1996.

13. Burden of disease due to leading regional risk factors divided by disease type – Developed regions Source: Ezzati M et al. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360:1347–1360

14. Most frequent causes of death in Germany in 2000(1) Source: StBA, Statistisches Jahrbuch (2002)

15. Most frequent causes of death in Germany in 2000(2) Source: StBA, Statistisches Jahrbuch (2002)

16. Women Men Prevalence of gross obesity (BMI 30) German National Health Survey 1998 (n= 7124) Source: Bergmann KE, Mensink GBM. Körpermaße und Übergewicht. Gesundheitswesen 1999; 61:S115–S120

17. Men West East hours per week: Sports activity in hours per week by age groups German National Health Survey 1998 Source:Mensink GBM. Körperliche Aktivität. Gesundheitswesen 1999; 61:S128–S131

18. Nutrition (diet)

19. 100 80 South Japan Eastern Finland 60 Relative frequency (%) 40 20 0 0 100 200 300 400 500 Total serum cholesterol (mg/100 ml) The contrasting distributions of serum cholesterol in South Japan and Eastern Finland Source:Rose G. The strategy of preventive medicine. Oxford University Press; 1992

20. Relative risks (95% CI) of CHD mortalityper 20 mg/dLcholesterol increase*in 6 cohortsof the Seven Countries Study(n = 12,467 men aged 40–59 years) * Adjusted for age, smoking, and systolic blood pressure; $ Based on average regression dilution factor of 1.4 Source: Verschuren et al. JAMA 1995; 274: 131–136

21. 25 year CHD mortality rates* in six cohorts of theSeven Countries Study per baseline cholesterol quartile(n = 12,467 men aged 40–59 years) *Adjusted for age, cigarette smoking, and systolic blood pressure Source: Verschuren et al. JAMA 1995; 274: 131–136

22. Cretan Dietary Habits (six commandments) • More bread • More vegetables and legumes • More fish • Replace meat (beef, pork, lamb) by poultry • No day without a fruit • Replace butter and cream by a special canola (rapeseed) oilmargarine*, rich in α linolenic acid * This margarine contains 5% of 18:3n -3 instead of 0,6% in olive oil. Source: Renaud SC. Prostagl. Leukotr. Essent. Fatty Acids 1997; 57: 423–427

23. The Lyon Diet Heart Study (secondary prevention trial):Endpoints over 27 months mean follow-up * Adjusted for age, sex, smoking, serum cholesterol, SBP, and infarct location. § Rates shown are per 100 patient-years of follow-up Source: Lorgeril M et al. Lancet 1994; 343: 1454–59

24. The Lyon Diet Heart Study: Survival curves, combined cardiac death and non-fatal acute myocardial infarction (AMI) Source: Lorgeril M et al. Lancet 1994; 343: 1458

25. Indo-Mediterranean Diet Heart Study – a randomisedsingle blind trial, n=1000 patients, 2 years follow-up Numbers and rate ratios for separate and combined cardiac endpoints * Adjusted for baseline age, gender, BMI, cholesterol and blood pressure. Source: Singh RB et al. Lancet 2002; 360: 1455–1461

26. Physical activity

27. Physical activity (e.g. brisk walking, jogging, bicycling, swimming) preferably daily and at least 30–45 minutes, reduces the risk in men and women for cardiovascular diseases by ~45% and for all cause mortality by 30–50%. Sources: Physical activity and health: a report of the Surgeon General. Centre for Disease Control and Prevention. Atlanta, 1996 Blair SN et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276: 205–210

28. Physical activity improves health in the following ways: • reduces risk of dying prematurely • reduces risk of dying from heart disease • reduces risk of developing diabetes mellitus • reduces risk of developing high blood pressure (BP) • helps reduce BP in people who already have high BP Source: Physical activity and health: a report of the Surgeon General. Centre for Disease Control and Prevention. Atlanta, 1996

29. Other documented health benefits include: • reduces the risk of developing colon cancer • reduces feelings of depression and anxiety • helps control weight • helps build healthy bones, muscles, and joints • helps older adults become stronger and better able to move about without falling • promotes psychological well-being Source: Physical activity and health: a report of the Surgeon General. Centre for Disease Control and Prevention. Atlanta, 1996

30. Smoking – Non Smoking

31. 669 / 105 413 / 105 140 / 105 10 / 105 Relative and attributable risks of mortality from lung cancer and CHD among cigarette smokers in a prospective study of34,000 male British doctors, 1951–1971 Source: Doll R, Peto R. Mortality in relation to smoking: 20 years' observations on male British doctors. BMJ 1976; 2: 1525–36

32. 80%  Never smoked regularly   Cigarettesmokers: % Survivors  50% 33%     8% Age Effects of cigarette smoking on survival to age 70 and to age 85, in 40-year prospective study of 34,000 male British doctors, 1951–1991 Source: Doll R, Peto R, Wheatley K et al. Mortality in relation to smoking. BMJ 1994; 309: 901–911

33. MONICA Augsburg Cohort Study 1984–1992 40 Arrows refer to synergism between smoking and hypercholesterolaemia 11.1 30 8.3 incidence rate (per 1000 py) 6.5 20 4.2 2.8 2.7 10 1.5 RR = 1.0 Risk factor combination: Actual Hypertension TC/HDL-C  5.5 Smoking ( 1 cig./day) Incident MIs / Population at risk: 0 1 0 0 1 1 0 1 0 1 1 1 1 0 1 1 0 0 0 0 0 1 0 1 0 8 / 373 4 / 133 7 / 110 9 / 149 7 / 75 4 / 35 16 / 107 6 / 33 Source: Keil et al. Eur Heart J 1998 Age-adjusted incidence rates and age-adjusted HRRs of non-fatal and fatal MI by the risk factors hypertension, TC/HDL-C  5.5, and smoking and by combinations of these risk factors, men

34. MONICA Augsburg Cohort Study 1984–1992 Population attributable fraction 0.0% 2.2% 7.2% 9.5% 8.8% 5.6% 23.1% 9.0% 40 11.1 30 8.3 6.5 20 incidence rate (per 1000 py) 4.2 2.8 10 2.7 1.5 HRR = 1.0 Risk factor combination: Actual Hypertension TC/HDL-C  5.5 Smoking (> 1 cig./day) 0 0 1 1 1 0 0 1 1 0 1 0 1 1 1 1 0 0 0 0 0 1 0 1 0 Population attributable fraction of non-fatal and fatal MI by the risk factors hypertension, TC/HDL-C  5.5, and smoking and their combinations, men

35. Annualsmokingdeaths (1000s) Males Females Smoking-attributed numbers of deaths per year All ages, Germany 1955–1995 Source: Peto, Lopez et al. 1992, 1994

36. Smoking – Cancer, cardiovascular diseases,and life expectancy • Smoking has caused more cancer than medicinehas even cured Richard Peto • Smoking reduces life expectancy by 8 yearsRichard Peto • Smoking is responsible for more deaths fromcardiovascular diseases than from lung cancerUlrich Keil

38. What can we achieve with changes in diet and lifestyle?

39. Primary prevention of coronary heart disease in women through diet and lifestyle (1) Prospective cohort study with data from the Nurse’s Health Study: 84.129 women, age 34–59 years, were followed from 1980–1994 During 14 years of follow-up 1.128 major coronary heart disease events were documented (296 fatal and 832 non-fatal events) Source: Stampfer MJ et al. N Engl J Med 2000; 343: 16–22

40. Primary prevention of coronary heart disease in women through diet and lifestyle (2) • Low-risk-subjects • non-smoking • BMI <25kg/m2 • moderate-to-vigorous physical activity  30 minutes/day • scored in the highest 40% of the cohort for a diet high in cereal fiber, marine n–3 fatty acids, and folate, with a high P/S ratio, and low in trans fat and glycemic load • alcohol 5g/day • Source: Stampfer MJ et al. N Engl J Med 2000; 343: 16–22

41. Risk of coronary heart disease (CHD) in low-risk groups in the Nurses’ Health Study 1980–1994 Source: Stampfer MJ et al. N Engl J Med 2000; 343: 16–22

42. THE CONFERENCE ON THE DECLINE IN CORONARY HEART DISEASE MORTALITY NATIONAL HEART, LUNG, AND BLOOD INSTITUTE NATIONAL INSTITUTES OF HEALTH BETHESDA (U.S.A.) October 24–25, 1978

45. Z uschauen(to watch) E ntspannen(to relax) N achdenken (to contemplate)

46. Der Mensch ist, was er isst. Ludwig Feuerbach1804 – 1872

47. Die größten Sünden werden in der Küche begangen Friedrich Nietzsche1844 – 1900

48. Vogel fliegt Fisch schwimmt Mensch läuft Emil Zátopek1922 – 2000

49. When the real causes have been removed,individual susceptibility ceases to matter Geoffrey Rose The Strategy of Preventive Medicine, 1992

50. The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart. Geoffrey Rose The Strategy of Preventive Medicine, 1992