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The power of lifestyle interventions to prevent cardiovascular diseases. Tuomilehto J. Conference on Cardiovascular Diseases (Madrid: Ministry of Health and Social Policy; 2010).
Citation preview
The power of lifestyle interventions to prevent cardiovascular disease
and type 2 diabetes.
Prof. Jaakko Tuomilehto
Department of Public Health,
University of Helsinki
DEVELOPED COUNTRIES – year 2000
Deaths attributable to 15 leading causes Cardiovascular diseases
Malignant neoplasms
Injuries
Respiratory diseases
Digestive diseases
Respiratory infections
Neuropsychiatric disorders
Diabetes mellitus
Diseases of the genitourinary system
Perinatal conditions
Tuberculosis
Nutritional/endocrine disorders
Other neoplasms
Congenital abnormalities Musculoskeletal diseases
98% of all deaths
attributable to
15 leading causes
0 1000 2000 3000 4000 5000 6000 7000 Source: WHR 2002
Number of deaths (000s)
DEVELOPED COUNTRIES – year 2000 Deaths attributable to selected leading risk factors
Blood pressure
Tobacco
Cholesterol
High Body Mass Index
Low fruit and vegetable intake
Physical inactivity
Alcohol
Urban air pollution
Lead exposure
Occupational carcinogens
Illicit drugs
Unsafe sex
Occupational particulates
Occupational risk factors for injury
0 500 1000 1500 2000 2500 3000
Number of deaths (000s)
-8 0000
-6 0000
-4 0000
-2 0000
0
WHO MONICA ProjectWHO MONICA Project
Fall in CHD mortality rates 27%
Event rates 21%
(incidence ≅≅≅≅≅≅≅≅ risk factors)
Case fatality –6%
(≅≅≅≅ treatments)
Monitored
10 year CHD trends from mid 1980s – mid 1990s
across 37 populations in 21 countries 166,000 events registered during 371 populationyears
Tunstall-Pedoe et al. Contribution of trends in survival & coronaryevent rates to changes in CHD mortality Lancet 1999 353 1547
Blood Pr ssure
e
Medical herapy
IMPACT Model: Main ComponentsIMPACT Model: Main Components
RISKRISK FF FACTORSFACTORS
PatientPatient GroupsGroups
TREATMENTSTREATMENTS
OUTCOMESOUTCOMES
e
AMI Angina Heart Failur 2' Prevention
T
Cholesterol
Smoking
Age & Sex
Physical Activity
BMI & Diabetes
Blood Pressure
UnU
Medical CABG/PTCA surgery
al, Critchley & Capewellnal, Critchley & Capewell
Circulation 2004 109(9) 1101Circulation 2004 109(9) 110177
SurvivalSurvivalDeath
MMoorrttaalliittyy ppeerr 700110000 000000
ssttaarrtt ooff tthhee NNoorrtthh KKaarreelliiaa PPrroojjeeccttppooppuullaattiioonn
600
extension of the Project nationally
AAggee--aaddjjuusstteedd CCHHDD mmoorrttaalliittyy rraattee iinn
500
NNoorrtthh KKaarreelliiaaNNoorrtthh KKaarreelliiaa aanndd tthhee wwhhoollee ooff
400
FFiinnllaanndd.. 300
-- 8822 %%MMeenn 3355--6644 yyeeaarrss AAllll FFiinnllaanndd
dduurriinngg 11996699 -- 22000022.. 200
-- 7755%% 100
69 72 75 78 81 84 87 90 93 96 99 2002
Year 29
Diastolic Blood Pressure
mmHg
95
90
85
80
75 1972 1977 1982 1987 1992 1997 2002
Women 30-59 Years
North Karelia Kuopio Turku/Loimaa Helsinki/Vantaa Oulu Province Lapland
Serum cholesterol in Finnish men aged 25-64 years
mmol/l
7
6,5
6
5,5
5 1982 1987 1992 1997 2002 2007
North Karelia Kuopio Turku/Loimaa Helsinki/Vantaa Oulu Lapland
Miehet
taarinensteroli
ttu S Kol
CHANGE IN SERUM CHOLESTEROL IN FINLAND 1982-2002*
-0,6
-0,5
-0,4
-0,3
-0,2
-0,1
0
0,1
1982 1992 2002
mm
ol/l
PUFA
Die kole
SFA
Keys
SFA+trans
Keys (trans) **
Mita -
Diet cholesterol
Measured serum cholesterol
MEN
Naiset
ietaarinenolesteroli
Mitattu S-Kol
CHANGE IN SERUM CHOLESTEROL IN FINLAND 1982-2002*
-0,6
-0,5
-0,4
-0,3
-0,2
-0,1
0
0,1
1982 1992 2002
mm
ol/l
PUFA
D k SFA
Keys
SFA+trans
Keys (trans) **
Measured serum cholesterol
Diet cholesterol
WOMEN
*
Use of butter on bread
% (men 30-59) 100 90 80 70 60 50 40 30 20 10 0
North Karelia Kuopio Turku/Loimaa Helsinki/Vantaa Oulu Lapland
1972 1977 1982 1987 1992 1997 2002
Use of vegetable oil (men 30-59)
70 North Karelia Kuopio 60 Turku/Loimaa
50 Helsinki/Vantaa Oulu
40 Lapland
30
20
10
0 1972 1977 1982 1987 1992 1997 2002
24-h sodium excretion as NaCl
YEAR
NaC
l g
1979 1982 1987 2002
6 8
10
12
14
16
18
20
Men, North Karelia
Men, Kuopio area
Men, Southwestern Finland
Men, Helsinki area
Women, North Karelia
Women, Kuopio area
Women, Southwestern Finland
Women, Helsinki area
Laatikainen et al. Eur J Clin Nutr 2006
Comparing the observed male mortality rates from CHD in N.E. Finland with those predicted from changes in the risk factors.
Vartiainen et al. 1994.
1975 1980 1985 1990 -70
-60
-50
-40
-30
-20
-10
0
Observed mortality
Smoking
Blood pressure
All three risks
Cholesterol
Per
cen
t de
clin
e
DPS: The Finnish Diabetes Prevention Study The main aim:
To determine whether lifestyle intervention of overweight, middle-aged subjects with impaired glucose tolerance (IGT) will prevent or delay the development of type 2 diabetes
Study subjects:
• 522 subjects with IGT in two oral glucose tolerance tests
• Age 40–65 years
• BMI > 25 kg/m2
• Randomization to standard care control group or
intensive lifestyle intervention group NN EEnnggll JJ MMeedd 22000011;; 334444::11334433
DPS - INTERVENTION GOALS
• Weight reduction: > 5% (BMI < 25 kg/m2) • Total fat intake: < 30 E% • Saturated fat intake: < 10 E% • Fiber intake: > 15 g/1000 kcal • Aerobic and muscle
strengthening exercise: > 30 min/day
Reduction of the incidence of diabetes during the lifestyle intervention - DPS
0.5
0.6
0.7
0.8
0.9
1.0
0 1 2 3 4 5 6
Year
Intervention groupControl group
Risk reduction: 58%
DDPPSS: Diabetes incidence by the randomization group
during the total extended follow-up period
50 Log-rank test: p=0.0001
ControlHazard ratio=0.57 (95% CI 0.43-0.76)
40
30
20
Intervention
10
IInntteerrvveennttiioonn cceeaasseedd
0
LLiinnddssttrröömm eett.. aall.. LLaanncceett 22000066;;336688::11667733--7799
Cu
mu
lati
ve in
cid
ence
of
T2D
, %
0 1 2 3 4 5 6 7 8
Follow-up time, years
Changes in clinical and metabolic parameters1
% 8 6 4 2 0
-2 -4 -6 -8
-10 -12
p<0.001 p<0.001 p<0.001 p<0.001
p=0.001
p<0.001
p=0.002
p=0.014 p=0.006
Weight Waist fPG 2-h PG fINS TG HDL SYST DIAS 1from baseline to year 1 subjects with the MetS Intervention Control
Proportion of subjects becoming diabetic by success in achieving the intervention targets at one-year
examination - DPS
0
5
10
15
20
25
30
35
40
45
50
0 1 2 3 4 5
Intervention Control
SUCCESS SCORE
%
1-year lifestyle changes in the Intervention and Control groups by FINDRISC
% 10,00
8,00
6,00
4,00
2,00
0,00
-2,00
-4,00
-6,00 Weight % Fat E% SaFat E% Fibre g / Exercise
1000kcal min/day
Intervention, low FINDRISC Intervention, high FINDRISC Control, low FINDRISC Control, high FINDRISC
p for interaction (FINDRISC*group) ns for all
-90
-80
-70
-60
-50
-40
-30
-20
-10
0 R
isk
redu
ctio
n (%
)
Change in total duration of leisure-time physical activity and the reduction in incidence of diabetes – DPS:
the highest tertile (3.8 h/wk) versus the lowest tertile (-3.2 h/wk)
Model 1 Model 2 Model 3*
* Adjusted for all baseline and follow-up variables
-80
-70
-60
-50
-40
-30
-20
-10
0 R
isk
redu
ctio
n (%
)
Change in duration of lifestyle leisure-time physical activity and the reduction in reduction in incidence of diabetes -DPS: the highest tertile (1.9 h/wk) versus the lowest tertile (-1.8 h/wk)
Model 1 Model 2 Model 3*
* Adjusted for all baseline and follow-up variables
Cumulative Incidence of Diabetes
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 Years of follow up
Per
cen
tag
e (%
)
Control Intervention
66%
43%
93%
80%
*Age and cluster variable clinic adjusted
HRR 0.57 (95% CI, 0.41 – 0.81) 11.3% / yr
6.9% / year
)
)
0
4
8
12
16
20
0 2 4 6 8 10 12 14 16 18 20
Years of follow up
Per
centa
ge (%
)
Control
Intervention
17% (0.9% / yr
13% (0.6 % / yr
Cumulative Incidence of CVD Death
1986-2006 HRR = 0.83 (95% CI 0.48 – 1.40) 1993-2006 HRR = 0.73 (95% CI 0.42 – 1.26)
Hazard ratios for total and CVD mortality according to leisure time activity among diabetic/IGT patients
- the Whitehall Study
Physical activity Total mortality CVD mortality
Low 1.65 (1.1-2.5) 3.60 (1.6-8.0)
Moderate 1.59 (1.1-2.4) 2.47 (1.1-5.4)
High 1.0 1.0
P for trend 0.03 0.02
Adjusted for age, BMI, systolic blood pressure, cholesterol, smoking and disease at study entry.
Batty et al. Diabet Med 2002;19:580–8.
Physical activity and CVD mortality among patients with type 2 diabetes –
The FINRISK Study
Multivariate-adjusted hazard ratios for total and CVD mortality among diabetic patients
- occupational physical activity
Occupational Total mortality CVD mortality
physical activity
Low 1.00 1.00
Moderate 0.86 (0.74-1.00) 0.91 (0.75-1.10)
Active 0.60 (0.52-0.69) 0.60 (0.50-0.71)
P for trend <0.001 <0.001
Adjusted for age, sex, study year, BMI, systolic blood pressure, cholesterol, smoking, and other two types of physical activity
Hu et al. Circulation 2004;110:666-73.
Multivariate-adjusted hazard ratios for total and CVD mortality among diabetic patients
- commuting physical activity
Walking or Total mortality CVD mortality
cycling to work
0 1.00 1.00
1-29 min/d 0.82 (0.71-0.94) 0.81 (0.67-0.96)
>=30 min/d 0.75 (0.64-0.87) 0.74 (0.61-0.90)
P for trend <0.001 0.002
Adjusted for age, sex, study year, BMI, systolic blood pressure, cholesterol, and smoking.
Hu et al. Circulation 2004;110:666-73.
Multivariate-adjusted hazard ratios for total and CVD mortality among diabetic patients
- leisure-time physical activity
Leisure-time Total mortality CVD mortality
physical activity
Low 1.00 1.00
Moderate 0.82 (0.73-0.91) 0.83 (0.72-0.95)
High 0.71 (0.56-0.92) 0.67 (0.49-0.93)
P for trend <0.001 0.005
Adjusted for age, sex, study year, BMI, systolic blood pressure, cholesterol, smoking, and other two types of physical activity
Hu et al. Circulation 2004;110:666-73.
Adjusted for age and sexAdjusted for age, sex, and region, education, BMI, physical activity, smokingAdjusted for all Interheart risk factors
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
0.5
1.0
2.0
Oriental Dietary Pattern Western Dietary Pattern Prudent Dietary Pattern Quartile
Odd
s R
atio
Age and sex adj Plus region, educ, BMI, physical activity, smoking adj All INTERHEART risk factors adj
Risk of AMI associated with Quartiles of Dietary Patterns (95% CI) - INTERHEART
Iqbal et al. Unpublished
OverallWomenMen
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
0.5
1.0
2.0
4.0
Overall Women Men Score Quartile
Odd
s R
atio
Overall Women Men
Risk of AMI associated with Quartiles of Dietary Risk Score (DRS) (95% CI) after adj for age, sex, region - INTERHEART
Iqbal et al. Unpublished
-
-
-
-
-
-
-
-
-
-
-
-
- -
-
-
-
-
-
-
-
- -
-
Population Attributable Risk and Odds Ratios for AMI associated with Dietary Risk Score- INTERHEART
0.5 1 2 4 8
OR (95% CI)OR (95% CI)
OR (95% CI)
PAR OR Q4 vs Q1
Overalla 0.30 (0.26 0.35)
1.92 (1.74 2.11)
Maleb 0.28 (0.23 0.33)
1.90 (1.70 2.11)
Femaleb 0.39 (0.30 0.49)
2.55 (2.00 3.23)
N. America, W. Europe
and Australiac
0.30 (0.17 0.42)
2.12 (1.61 2.78)
Central Europec 0.31 (0.18 0.44)
1.61 (1.20 2.15)
Middle Eastc 0.28 (0.17 0.40)
1.81 (1.41 2.33)
Africac 0.10 ( 0.14 0.35)
1.27 (0.82 1.97)
South Asiac 0.29 (0.18 0.40)
1.85 (1.46 2.34)
Chinac 0.18 (0.07 0.29)
2.02 (1.65 2.48)
Southeast Asiac 0.58 (0.45 0.71)
4.27 (2.87 6.35)
S. Americac 0.15 ( 0.03 0.32)
1.80 (1.30 2.49)
a adjusted for age, sex and regions b adjusted for age and regions c Adjusted for age and sex
Iqbal et al.