The power of lifestyle interventions to prevent cardiovascular diseases

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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).

The power of lifestyle interventions to prevent cardiovascular diseases. Tuomilehto J. Conference on Cardiovascular Diseases (Madrid: Ministry of Health and Social Policy; 2010).

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  • 1. The power of lifestyle interventions to prevent cardiovascular disease and type 2 diabetes. Prof. Jaakko Tuomilehto Department of Public Health,  University of Helsinki
  • 2. 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 98% of all deaths Diseases of the genitourinary system attributable to Perinatal conditions 15 leading causes    Tuberculosis Nutritional/endocrine disorders Other  neoplasms Congenital abnormalities Musculoskeletal diseases 0 1000 2000 3000 4000 5000 6000 7000 Source: WHR 2002 Number of deaths (000s)
  • 3. 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)
  • 4. WHO MONICA Project Monitored  10 year CHD trends from mid 1980s – mid 1990s  across 37 populations in 21 countries 166,000 events registered during 371 population­years 0 Fall in CHD mortality rates ­27% -2 0 0 0 0 Event rates ­21% -4 0 0 0 0 (incidence ≅ risk factors) -6 0 0 0 0 Case fatality  –6% ≅ (≅ treatments) -8 0 0 0 0 Tunstall-Pedoe et al. Contribution of trends in survival & coronary­ event rates to changes in CHD mortality Lancet 1999 353 1547
  • 5. IMPACT Model: Main Components Cholesterol BMI & Diabetes RISK Blood Pressure Activity Smoking Physical F FACTORS Blood Pressure Age & Sex Patient Groups AMI Angina Heart Failure 2' Prevention CABG/PTCA TREATMENTS Medical Therapy Medical surgery OUTCOMES Death Survival Unal, Critchley & Capewell    Unal, Circulation 2004  109(9)  1101­7 1101­
  • 6. Mortality per 100 000 700 start of the North Karelia Project population 600 extension of the Project nationally Age-adjusted CHD 500 mortality rate in North Karelia and North Karelia 400 the whole of Finland. 300 Men 35-64 years - 82 % 200 All Finland during 1969 - 2002. - 75% 100 69 72 75 78 81 84 87 90 93 96 99 2002 Year 29
  • 7. Diastolic Blood Pressure mmHg Women 30-59 Years 95 90 North Karelia Kuopio Turku/Loimaa 85 Helsinki/Vantaa Oulu Province 80 Lapland 75 1972 1977 1982 1987 1992 1997 2002
  • 8. Serum cholesterol in Finnish men aged 25-64 years mmol/l 7 6,5 North Karelia Kuopio Turku/Loimaa 6 Helsinki/Vantaa Oulu 5,5 Lapland 5 1982 1987 1992 1997 2002 2007
  • 9. CHANGE IN SERUM CHOLESTEROL IN FINLAND 1982-2002* MEN Miehet 0,1 PUFA 0 Diet cholesterol Dietaarinen kolesteroli -0,1 SFA -0,2 mmol/l Keys -0,3 SFA+trans -0,4 Keys (trans) ** -0,5 Mitattu S-Kol Measured serum -0,6 cholesterol 1982 1992 2002
  • 10. CHANGE IN SERUM CHOLESTEROL IN FINLAND 1982-2002* WOMEN Naiset 0,1 PUFA 0 Diet cholesterol Dietaarinen kolesteroli -0,1 SFA mmol/l -0,2 Keys -0,3 SFA+trans -0,4 Keys (trans) ** -0,5 Mitattu S-Kol Measured serum -0,6 cholesterol 1982 1992 2002 *
  • 11. Use of butter on bread % (men 30-59) 100 North Karelia 90 Kuopio 80 Turku/Loimaa 70 Helsinki/Vantaa Oulu 60 Lapland 50 40 30 20 10 0 1972 1977 1982 1987 1992 1997 2002
  • 12. Use of vegetable oil (men 30-59) 70 North Karelia 60 Kuopio Turku/Loimaa 50 Helsinki/Vantaa Oulu 40 Lapland 30 20 10 0 1972 1977 1982 1987 1992 1997 2002
  • 13. 24-h sodium excretion as NaCl 20 Men, North Karelia 18 Men, Kuopio area Men, Southwestern Finland Men, Helsinki area 16 Women, North Karelia Women, Kuopio area 14 NaCl g Women, Southwestern Finland Women, Helsinki area 12 10 8 6 1979 1982 1987 2002 YEAR Laatikainen et al. Eur J Clin Nutr 2006
  • 14. Comparing the observed male mortality rates from CHD in N.E. Finland with those predicted from changes in the risk factors. 0 Smoking -10 Blood pressure -20 Percent decline Cholesterol -30 -40 All three risks -50 Observed mortality -60 -70 1975 1980 1985 1990 Vartiainen et al. 1994.
  • 15. 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 N Engl J Med 2001; 344:1343
  • 16. 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
  • 17. Reduction of the incidence of diabetes during the lifestyle intervention - DPS 1.0 0.9 0.8 0.7 0.6 Risk reduction: 58% 0.5 Intervention 0 1 2 3 4 5 6 group Control group Year
  • 18. DPS: Diabetes incidence by the randomization group during the total extended follow-up period 50 Log-rank test: p=0.0001 Cumulative incidence of T2D, % Control Hazard ratio=0.57 (95% CI 0.43-0.76) 40 30 20 Intervention 10 Intervention ceased 0 0 1 2 3 4 5 6 7 8 Follow-up time, years Lindström et. al. Lancet 2006;368:1673-79
  • 19. Changes in clinical and metabolic parameters1 % 8 p<0.001 6 p=0.001 4 2 p<0.001 p<0.001 p<0.001 p<0.001 p=0.014 p=0.006 0 p=0.002 -2 -4 -6 -8 -10 -12 Weight Waist fPG 2-h PG fINS TG HDL SYST DIAS 1frombaseline to year 1 Intervention Control subjects with the MetS
  • 20. Proportion of subjects becoming diabetic by success in achieving the intervention targets at one-year examination - DPS 50 % 45 40 Intervention Control 35 30 25 20 15 10 5 0 0 1 2 3 4 5 SUCCESS SCORE
  • 21. 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
  • 22. 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* 0 -10 Risk reduction (%) -20 -30 -40 -50 -60 -70 -80 -90 * Adjusted for all baseline and follow-up variables
  • 23. 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* 0 -10 Risk reduction (%) -20 -30 -40 -50 -60 -70 -80 * Adjusted for all baseline and follow-up variables
  • 24. Cumulative Incidence of Diabetes 100 HRR 0.57 (95% CI, 0.41 – 0.81) 93% 11.3% / yr 80 Percentage (%) 66% 80% 6.9% / year 60 40 43% Control Intervention 20 0 0 2 4 6 8 10 12 14 16 18 20 Years of follow up *Age and cluster variable clinic adjusted
  • 25. Cumulative Incidence of CVD Death 20 17% 1986-2006 HRR = 0.83 (95% CI 0.48 – 1.40) (0.9% / yr) 1993-2006 HRR = 0.73 (95% CI 0.42 – 1.26) 16 Percentage (%) 12 13% Control (0.6 % / yr ) 8 Intervention 4 0 0 2 4 6 8 10 12 14 16 18 20 Years of follow up
  • 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.
  • 27. Physical activity and CVD mortality among patients with type 2 diabetes – The FINRISK Study
  • 28. 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.
  • 29. 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.
  • 30. 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.
  • 31. Risk of AMI associated with Quartiles of Dietary Patterns (95% CI) - INTERHEART 2.0 Age and for ageadj sex sex and Adjusted Plus region, educ, BMI, physical activity,activity, smokingadj Adjusted for age, sex, and region, education, BMI, physical smoking Adjusted for all Interheart risk factors All INTERHEART risk factors adj Odds Ratio 1.0 0.5 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Oriental Dietary Pattern Western Dietary Pattern Prudent Dietary Pattern Quartile Iqbal et al. Unpublished
  • 32. Risk of AMI associated with Quartiles of Dietary Risk Score (DRS) (95% CI) after adj for age, sex, region - INTERHEART 4.0 Overall Overall Women Women Men Men Odds Ratio 2.0 1.0 0.5 Q 1 Q2 Q3 Q4 Q1 Q 2 Q3 Q4 Q1 Q2 Q3 Q4 Overall Women Men Score Quartile Iqbal et al. Unpublished
  • 33. OR (95% CI) Population Attributable Risk and Odds Ratios for AMI associated with Dietary Risk Score- INTERHEART OR PAR Q4 vs Q1 0.30 1.92 Overalla (0.26-0.35) (1.74-2.11) 0.28 1.90 Maleb (0.23-0.33) (1.70-2.11) 0.39 2.55 Femaleb (0.30-0.49) (2.00-3.23) N. America, W. 0.30 2.12 Europe (0.17-0.42) (1.61-2.78) and Australiac 0.31 1.61 Central Europec (0.18-0.44) (1.20-2.15) 0.28 1.81 Middle Eastc (0.17-0.40) (1.41-2.33) 0.10 1.27 Africac (-0.14-0.35) (0.82-1.97) 0.29 1.85 South Asiac (0.18-0.40) (1.46-2.34) 0.18 2.02 Chinac (0.07-0.29) (1.65-2.48) 0.58 4.27 Southeast Asiac (0.45-0.71) (2.87-6.35) 0.15 1.80 S. Americac (-0.03-0.32) (1.30-2.49) a adjusted for age, sex and regions 0.5 1 2 4 8 b adjusted for age and regions c Adjusted for age and sex OR (95% CI) Iqbal et al.