Eine vitale Gesellschaft

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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
WHO Collaborating Centre for Epidemiology and
Preventionof Cardiovascular and Other Chronic
Diseases
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Growing of the world population
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Source Statistisches Bundesamt, Bundesinstitut
für Bevölkerungsstudien
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Population of Germany by age groups19501998
Age groups in Age groups in Age groups in Age groups in
Year lt20 years 2029 years 3059 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
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Life expectancy at birth for men in Europe 1991
and 1998
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Life expectancy at birth for women in Europe 1991
and 1998
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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 42125
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Change in rank order of leading causes of death
(world)
1990 Disease or injury
2020 Disease or injury
baseline scenarios
Source Murray CJL, Lopez AD. The Global Burden
of Disease. Cambridge Harvard University Press,
1996.
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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 36013471360
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Most frequent causes of death in Germany in 2000
(1)
Source StBA, Statistisches Jahrbuch (2002)
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Most frequent causes of death in Germany in 2000
(2)
Source StBA, Statistisches Jahrbuch (2002)
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Prevalence of gross obesity (BMI ?30) German
National Health Survey 1998 (n 7124)
Source Bergmann KE, Mensink GBM. Körpermaße und
Übergewicht. Gesundheitswesen 1999 61S115S120
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Sports activity in hours per week by age
groups German National Health Survey 1998
Source Mensink GBM. Körperliche Aktivität.
Gesundheitswesen 1999 61S128S131
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Nutrition (diet)
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The contrasting distributions of serum
cholesterol in South Japan and Eastern Finland
Source Rose G. The strategy of preventive
medicine. Oxford University Press 1992
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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 4059
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 131136
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25 year CHD mortality rates in six cohorts of
theSeven Countries Study per baseline
cholesterol quartile(n 12,467 men aged 4059
years)
Adjusted for age, cigarette smoking, and
systolic blood pressure Source Verschuren et al.
JAMA 1995 274 131136
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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 a linolenic
  acid

This margarine contains 5 of 183n -3 instead
of 0,6 in olive oil. Source Renaud SC.
Prostagl. Leukotr. Essent. Fatty Acids 1997 57
423427
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The Lyon Diet Heart Study (secondary prevention
trial)Endpoints over 27 months mean follow-up
Control (n303) person-years 594 Control (n303) person-years 594 Experim. (n302) person-years 606 Experim. (n302) person-years 606 Cox Proportional- Hazards model Cox Proportional- Hazards model
events (n) Rate events (n) Rate HRR 95 CI
Cardiovascular deaths 16 2.69 3 0.50 0.24 0.070.85
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 145459
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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
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Indo-Mediterranean Diet Heart Study a
randomisedsingle blind trial, n1000 patients, 2
years follow-up Numbers and rate ratios for
separate and combined cardiac endpoints
Control (n501) person-weeks 46554 Control (n501) person-weeks 46554 Experim. (n499) person-weeks 49238 Experim. (n499) person-weeks 49238 Adjusted rate ratios (Cox Model) Adjusted rate ratios (Cox Model)
events (n) () events (n) () HRR 95 CI
Non-fatal MI 43 (8.6) 21 (4.2) 0.47 0.280.79
Fatal MI 17 (3.4) 12 (2.4) 0.67 0.311.42
Sudden cardiac death 16 (3.2) 6 (1.2) 0.33 0.130.86
Total cardiac endpoints 76 (15.2) 39 (7.8) 0.48 0.33 0.71
Total deaths 38 (8.0) 24 (5.0) ?lt0.0640 ?lt0.0640
Adjusted for baseline age, gender, BMI,
cholesterol and blood pressure. Source Singh RB
et al. Lancet 2002 360 14551461
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Physical activity
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Physical activity (e.g. brisk walking, jogging,
bicycling, swimming) preferably daily and at
least 3045 minutes, reduces the risk in men and
women for cardiovascular diseases by 45 and
for all cause mortality by 3050. Sources Physi
cal 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 205210
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• 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
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• 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
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Smoking Non Smoking
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Relative and attributable risks of mortality from
lung cancer and CHD among cigarette smokers in a
prospective study of34,000 male British doctors,
19511971
Source Doll R, Peto R. Mortality in relation to
smoking 20 years' observations on male British
doctors. BMJ 1976 2 152536
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Effects of cigarette smoking on survival to age
70 and to age 85, in 40-year prospective study of
34,000 male British doctors, 19511991
Source Doll R, Peto R, Wheatley K et al.
Mortality in relation to smoking. BMJ 1994 309
901911
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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
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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
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Smoking-attributed numbers of deaths per year All
ages, Germany 19551995
Source Peto, Lopez et al. 1992, 1994
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Smoking Cancer, cardiovascular diseases,and
life expectancy

• Smoking has caused more cancer than medicinehas
  even cured Richard Peto
• Smoking reduces life expectancy by 8
  years Richard Peto
• Smoking is responsible for more deaths
  fromcardiovascular diseases than from lung
  cancer Ulrich Keil

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What can we achieve with changes in diet and
lifestyle?
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Primary prevention of coronary heart disease in
women through diet and lifestyle (1)
Prospective cohort study with data from the
Nurses Health Study 84.129 women, age 3459
years, were followed from 19801994 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 1622
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Primary prevention of coronary heart disease in
women through diet and lifestyle (2)

• Low-risk-subjects
• non-smoking
• BMI lt 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 n3 fatty
  acids, and folate, with a high P/S ratio, and low
  in trans fat and glycemic load
• alcohol ? 5 g/day
• Source Stampfer MJ et al. N Engl J Med 2000
  343 1622

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Risk of coronary heart disease (CHD) in low-risk
groups in the Nurses Health Study 19801994
Source Stampfer MJ et al. N Engl J Med 2000
343 1622
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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 2425, 1978
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Z uschauen (to watch) E ntspannen (to
relax) N achdenken (to contemplate)
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Der Mensch ist, was er isst.
Ludwig Feuerbach1804 1872
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Die größten Sünden werden in der Küche begangen
Friedrich Nietzsche1844 1900
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Vogel fliegt Fisch schwimmt Mensch läuft
Emil Zátopek1922 2000
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When the real causes have been removed,individual
susceptibility ceases to matter
Geoffrey Rose The Strategy of Preventive
Medicine, 1992
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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
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Die Medizin ist eine soziale Wissenschaftund die
Politik ist weiter nichtsals eine Medizin im
Großen.
Rudolf Virchow1821 1902
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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
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Anhang
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Percentage () of deaths (cancer, all causes)
caused by smoking / of all deaths in 1000,in
Germany 1990
Source Peto, Lopez et al. 1992, 1994
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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
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The most frequent hospital discharge diagnoses
for male patients Germany 1999
Source Statistisches Bundesamt.
Gesundheitswesen. Fachserie 12, Reihe 1, 1999, S.
109
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Early retirement (Berufs- und Erwerbsunfähigkeit)
by cause and gender Germany 1999
Source Statistisches Bundesamt.
Gesundheitswesen. Fachserie 12, Reihe 1, 1999, S.
159