vitale gesellschaft health and disease in germany, europe and worldwide: facts, predictions and...

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

AS\05\03: VitalGes_Münster01.ppt

Vitale Gesellschaft – Münster 2003

Growing of the world population

According to the UN the world population reached6 billion on October 12, 1999.

1804 1 billion people




prognosis for 2050 9 billion people

122 years

34 years

39 years

Source: Statistisches Bundesamt, Bundesinstitut für Bevölkerungsstudien



Population of Germany by age groups1950–1998

Age groups in %

Year <20 years 20–29 years 30–59 years 60 years

1950 30.4 14.1 40.9 14.6

1970 30.0 12.9 37.1 19.9

1990 21.7 16.7 41.2 20.4

1998 21.4 12.3 43.9 22.4

Source: Statistisches Bundesamt

Life expectancy at birth for men in Europe1991 and 1998

Source: WHO – European health for all database (HFA-DB) – www.who.dk/hfadb * 1997

60 62 64 66 68 70 72 74 76 78 80

Russia

Hungary

Romania

Poland

Europe

Portugal

Finland

Germany

Austria

EU average

UK

France

Spain

Netherlands

Greece

Italy

Israel*

Sweden

1991

1998

years

EU average

Europe

Germany

77.0

74.6

Life expectancy at birth for women in Europe1991 and 1998

Source: WHO – European health for all database (HFA-DB) – www.who.dk/hfadb * 1997

70 72 74 76 78 80 82 84 86

Russia

Romania

Hungary

Poland

Europe

Portugal

UK

Israel*

Germany

Greece

Netherlands

Austria

Finland

EU average

Sweden

Italy

Spain

France

1991

1998

years

EU average

Europe

Germany

82.7

80.8

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

Age group (years)

Cause of death 1 1–34 35–64 65 All ages

Infectious and parasitic diseases 0.30 0.10 0.08 – 0.01 0.47

Cancer 0 0.05 0.25 – 0.35 – 0.05

Cardiovascular diseases 0 0.07 1.36 1.85 3.28

Respiratory diseases 0.68 0.20 0.15 – 0.05 0.97

Digestive diseases 0.02 0.03 0.08 – 0.04 0.09

External causes 0.04 0.64 0.71 0.03 1.41

Ill defined conditions – 0.10 0.01 0.04 0.18 0.12

Other diseases 0 0 – 0.02 –0.20 – 0.22

All causes 0.93 1.09 2.63 1.40 6.06

Source: Bobak, M and Marmot, M. East-West mortality divide and its potential explanations. BMJ 1996; 312: 421–25

Change in rank order of leading causes of death (world)

1990Disease or injury

2020*Disease or injury

1 Ischaemic heart disease

2 Cerebrovascular disease

3 Chronic obstructive pulmonary disease

4 Lower respiratory infections

5 Trachea, bronchus and lung cancers

6 Road traffic accidents

7 Tuberculosis

8 Stomach cancer

9 HIV

10 Self-inflicted injuries

11

16

27* baseline scenarios

Source: Murray CJL, Lopez AD. The Global Burden of Disease. Cambridge: Harvard University Press, 1996.

Ischaemic heart disease 1

Cerebrovascular disease 2

Lower respiratory infections 3

Diarrhoeal diseases 4

Conditions arising during the perinatalperiod

5

Chronic obstructive pulmonary disease 6

Tuberculosis 7

Measles 8

Road traffic accidents 9

Trachea, bronchus and lung cancers 10

12

14

30

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

Causes of death (ICD-10) Deaths

(men and women)

Total 838,797

Cardiovascular diseases (I 00–I 99) 395,043

Ischemic heart disease (I 120–I 125) 167,681

Stroke (I 160–I 169) 80,786

Neoplasms (C00–C97) 210,738

Lung cancer (including larynx and trachea) (C32–C 34) 40,553

Colon and rectum cancer (C18–C21) 28,987

Breast cancer in women (C50) 17,814

Lymphatic and hematopoietic system (C81–C96) 16,186

Prostate cancer (C61) 11,107

Bladder cancer (C67) 5,977

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

Source: StBA, Statistisches Jahrbuch (2002)

Causes of death (ICD-10) Deaths

(men and women)

Pneumonia (J10–J18) 18,757

COPD (J40–J47) 25,798

Chronic liver disease and -zirrhosis (K70–K77) 18,428

Diabetes mellitus (E10–E14) 21,180

Suicide (X60–X84) 11,065

Traffic accidents (V01–V99) 7,747

Falls (W00–W19) 7,404

HIV / AIDS (B20–B24) 580

Sudden infant death syndrome (SIDS) (R95) 482

Severe acute respiratory syndrome (SARS) 0

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

Source: StBA, Statistisches Jahrbuch (2002)



Prevalence of gross obesity (BMI 30)German National Health Survey 1998 (n= 7124)

0

10

20

30

40

50

18

-19

20

-29

30

-39

40

-49

50

-59

60

-69

70

-79

18

-19

20

-29

30

-39

40

-49

50

-59

60

-69

70

-79

Age

%

WestEast

Men Women

Source: Bergmann KE, Mensink GBM. Körpermaße und Übergewicht. Gesundheitswesen 1999; 61:S115–S120



Sports activity in hours per week by age groupsGerman National Health Survey 1998

Source: Mensink GBM. Körperliche Aktivität. Gesundheitswesen 1999; 61:S128–S131

0%

20%

40%

60%

80%

100%

18

-19

20

-29

30

-39

40

-49

50

-59

60

-69

70

-79

18

-19

20

-29

30

-39

40

-49

50

-59

60

-69

70

-79

Age

none <1 1-2 2-4 >4

West EastMen

hours per week:



Nutrition (diet)



0 100 200 300 400 5000

20

40

60

80

100

South Japan Eastern Finland

Rel

ativ

e fr

eque

ncy

(%)

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



Relative risks (95% CI) of CHD mortality per 20 mg/dLcholesterol increase* in 6 cohorts of 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

Cohort Unadjusted for

regression dilution Adjusted for

regression dilution

Northern Europe 1.12 (1.08–1.15) 1.18

United States 1.15 (1.10–1.19) 1.21

Southern Europe, Inland 1.10 (1.04–1.16) 1.14

Southern Europe, Mediterranean 1.12 (1.04–1.22) 1.18

Serbia 1.11 (0.97–1.28) 1.14

Japan 0.96 (0.77–1.18) Not available

Overall 1.12 (1.09–1.16) 1.17$

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

Serum total cholesterol, mg/dL

100 125 150 175 200 225 250 275 300 325 350

CH

D m

orta

lity

rate

s %

0

5

10

15

20

25

30

35

Northern EuropeUnited StatesSerbiaSouthern Europe, InlandSouthern Europe, MediterraneanJapan



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



The Lyon Diet Heart Study (secondary prevention trial):Endpoints over 27 months mean follow-up

Control (n=303) person-years 594

Experim. (n=302) person-years 606

Cox Proportional- Hazards model*

events (n) Rate§ events (n) Rate§ HRR 95% CI

Cardiovascular deaths 16 2.69 3 0.50 0.24 0.07–0.85

Non-fatal MI 17 2.86 5 0.82

Total major primary endpoints

33 5.55 8 1.32 0.27 0.12 –0.59

Non-cardiovascular deaths 4 0.67 5 0.82

Overall mortality 20 3.37 8 1.32 0.30 0.11 –0.82

* 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



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

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

Control (n=501) person-weeks

46554

Experim. (n=499) person-weeks

49238

Adjusted* rate ratios (Cox Model)

events (n) (%) events (n) (%) HRR 95% CI

Non-fatal MI 43 (8.6) 21 (4.2) 0.47 0.28–0.79

Fatal MI 17 (3.4) 12 (2.4) 0.67 0.31–1.42

Sudden cardiac death 16 (3.2) 6 (1.2) 0.33 0.13–0.86

Total cardiac endpoints 76 (15.2) 39 (7.8) 0.48 0.33 –0.71

Total deaths 38 (8.0) 24 (5.0) р<0.0640

* Adjusted for baseline age, gender, BMI, cholesterol and blood pressure.

Source: Singh RB et al. Lancet 2002; 360: 1455–1461



Physical activity



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 mortalityin men and women. JAMA 1996; 276: 205–210



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



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-beingSource: Physical activity and health: a report of the Surgeon General. Centre for Disease Control and Prevention. Atlanta, 1996



Smoking – Non Smoking



Relative and attributable risks of mortality from lung cancer and CHD among cigarette smokers in a prospective study of

34,000 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

Annual mortality rates per 100,000 Lung cancer Coronary heart disease Cigarette smokers 140 669 Nonsmokers 10 413

Relative risk = 14.0 = 1.6 Attributable risk 130 / 105 / year 256 / 105 / year

140 / 105

10 / 105

669 / 105

413 / 105

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

Age

% S

urv

ivo

rs

40 55 70 85 1000

20

40

60

80

100

1–14 / day 15–24 / day 25+ / day

Never smoked regularly

33%

8%

80%

50%Cigarettesmokers:

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

0

20

30

40

10inci

den

ce

rate

(p

er 1

000

py)

RR = 1.0

2.72.8

4.2

6.5

8.3

11.1

1.5

000

111

011

101

110

010

100

001

8 / 373 4 / 133 7 / 110 7 / 75 4 / 35 16 / 107 6 / 339 / 149

Risk factorcombination: Actual Hypertension TC/HDL-C 5.5Smoking ( 1 cig./day)

Incident MIs / Population at risk:

Arrows refer to synergism between smoking and hypercholesterolaemia

Source: Keil et al. Eur Heart J 1998

MONICA Augsburg Cohort Study 1984–1992

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

0

20

30

40

10

inci

den

ce

rate

(p

er 1

000

py)

HRR = 1.0

2.72.8

4.2

6.5

8.3

11.1

1.5

000

111

011

101

110

010

100

001

0.0% 2.2% 7.2% 8.8% 5.6% 23.1% 9.0%9.5%

Risk factorcombination:

Actual HypertensionTC/HDL-C 5.5Smoking (> 1 cig./day)

Population attributable fraction

MONICA Augsburg Cohort Study 1984–1992



Smoking-attributed numbers of deaths per yearAll ages, Germany 1955–1995

Source: Peto, Lopez et al. 1992, 1994

7,61

7,111

17 20

44

89

109100

9588

0

20

40

60

80

100

120

1955 1965 1975 1985 1990 1995

Males

Females

Annualsmokingdeaths(1000s)



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 cancer

Ulrich Keil



What can we achieve with changes in diet and lifestyle?



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



Primary prevention of coronary heart disease in women through diet and lifestyle (2)

Low-risk-subjects

• non-smoking

• BMI < 25 kg/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 5 g/day




Risk of coronary heart disease (CHD) in low-risk groups in the Nurses’ Health Study 1980–1994


Group % of women

in group

Number of CHD events

Rel. Risk (95% CI)

Attributable Risk

(95% CI) %

Three low-risk factors Diet in upper 40% Nonsmoking, exercise 30 min/day

12.7 62 0.43 (0.33 – 0.55)

54 (42 – 64)

Four low-risk factors

Diet in upper 40% Nonsmoking, exercise 30 min/day, BMI < 25

7.2 24 0.34 (0.23 – 0.52)

64 (46 – 76)

Five low-risk factors

Diet in upper 40% Nonsmoking, exercise 30 min/day, BMI < 25 Alcohol 5 g/day

3.1 5 0.17 (0.07 – 0.41)

82 (58 – 93)



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



Z uschauen (to watch)

E ntspannen (to relax)

N achdenken (to contemplate)

Der Mensch ist, was er isst.

Ludwig Feuerbach

1804 – 1872

Die größten Sünden werden in der Küche begangen

Friedrich Nietzsche

1844 – 1900



Vogel fliegt

Fisch schwimmt

Mensch läuft

Emil Zátopek

1922 – 2000



When the real causes have been removed,

individual susceptibility ceases to matter

Geoffrey Rose

The Strategy of Preventive Medicine, 1992



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




Die Medizin ist eine soziale Wissenschaft

und die Politik ist weiter nichts

als eine Medizin im Großen.

Rudolf Virchow

1821 – 1902



Geoffrey Rose


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.



Anhang



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

in Germany 1990

Men Women Total

Neoplasms 39 / 103 4,4 / 102 43 / 205 (38 %) (4 %) (21 %) All causes 95 / 425 17 / 496 112 / 921 of deaths (22 %) (3 %) (12 %)

Source: Peto, Lopez et al. 1992, 1994



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

Incident cases

ICD-9 Diagnosis groups / reasons for treatment n

410 + 414 Akuter Myokardinfarkt und chronische ischämische Herzkrankheiten 466.695

550 Leistenbruch 166.989

780 Allgemeine Symptome (Schwindel, Schlafstörung, Asthenie) 153.255

427 Herzrhythmusstörungen 137.511

303 Alkoholabhängigkeit 130.393

162 Bösartige Neubildungen der Luftröhre, Bronchien und Lunge 123.825

850 Commotio cerebri (Gehirnerschütterung) 113.965

428 Herzinsuffizienz 107.344

474 Chronische Affektionen der Tonsillen und des adenoiden Gewebes 103.104

717 Innere Kniegelenkschädigung (Meniskusschäden) 102.895

715 Osteoarthrose und entsprechende Affektionen 102.386

592 Nieren- und Harnleitersteine 95.439

The most frequent hospital discharge diagnoses for male patients Germany 1999

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



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

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

0 10 20 30 40

early retirements in thousands

MenWomen

Neoplasms(ICD-9 140–208)

Cardiovascular diseases(ICD-9 390–459)

Respiratory diseases(ICD-9 460–519)

Accidents and poisonings(ICD-9 800–999)

vitale gesellschaft health and disease in germany, europe and worldwide: facts, predictions and...

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