The power of lifestyle interventions to prevent cardiovascular diseases

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.


- 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.



- 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


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

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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.

The power of lifestyle interventions to prevent cardiovascular diseases

Health & Medicine

Transcript of The power of lifestyle interventions to prevent cardiovascular diseases