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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.

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slide1

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

slide2

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

slide6

Population of Germany by age groups1950–1998

Source: Statistisches Bundesamt

slide8

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

slide9

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

slide10

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

slide12

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.

slide13

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

slide14

Most frequent causes of death in Germany in 2000(1)

Source: StBA, Statistisches Jahrbuch (2002)

slide15

Most frequent causes of death in Germany in 2000(2)

Source: StBA, Statistisches Jahrbuch (2002)

slide16

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

slide17

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

slide19

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

slide20

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

slide21

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

slide22

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

slide23

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

slide24

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

slide25

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

slide27

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

slide28

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

slide29

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

slide31

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

slide32

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

slide33

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

slide34

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

slide35

Annualsmokingdeaths

(1000s)

Males

Females

Smoking-attributed numbers of deaths per year

All ages, Germany 1955–1995

Source: Peto, Lopez et al. 1992, 1994

slide36

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
slide39

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

slide40

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
slide41

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

slide42

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

slide45

Z uschauen(to watch)

E ntspannen(to relax)

N achdenken (to contemplate)

slide46

Der Mensch ist, was er isst.

Ludwig Feuerbach1804 – 1872

slide48

Vogel fliegt

Fisch schwimmt

Mensch läuft

Emil Zátopek1922 – 2000

slide49

When the real causes have been removed,individual susceptibility ceases to matter

Geoffrey Rose

The Strategy of Preventive Medicine, 1992

slide50

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

slide51

Die Medizin ist eine soziale Wissenschaftund die Politik ist weiter nichtsals eine Medizin im Großen.

Rudolf Virchow1821 – 1902

slide52

It is better to be healthy than ill or dead. That is the beginning and the end of the only real argument for preventive medicine. It is sufficient.

Geoffrey Rose

The Strategy of Preventive Medicine, 1992

slide54

Percentage (%) of deaths (cancer, all causes) caused by smoking / of all deaths in 1000,in Germany 1990

Source: Peto, Lopez et al. 1992, 1994

slide55

Incident cases

The most frequent cancers as a percentage of all cancers Germany1998

Source: AG Bevölkerungsbezogener Krebsregister in Deutschland. Krebs in Deutschland. 3. Ausgabe, Saarbrücken, 2002, S. 9

slide56

The most frequent hospital discharge diagnoses for male patients Germany 1999

Source: Statistisches Bundesamt. Gesundheitswesen. Fachserie 12, Reihe 1, 1999, S. 109

slide57

Neoplasms

(ICD-9 140–208)

Cardiovascular diseases

(ICD-9 390–459)

Respiratory diseases

(ICD-9 460–519)

Accidents and poisonings

(ICD-9 800–999)

Early retirement (Berufs- und Erwerbsunfähigkeit) by cause and gender Germany 1999

Source: Statistisches Bundesamt. Gesundheitswesen. Fachserie 12, Reihe 1, 1999, S. 159