Heart Health A public health perspective

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Heart HealthA public health perspective

• Ivan J Perry
• Department of Epidemiology Public Health
• University College Cork

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Public Health
Process of mobilising local, regional, national
and international resources to ensure the
conditions in which people can be healthy
Detels and Breslow (1997)
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Lifestyle and Health

• Core lifestyle determinants of health
• Limitations of the lifestyle paradigm in
  Public Health
• Health issues for the individual and the state,
  examples of obesity
• Personal responsibility and the Nanny state
• Public health and human rights
• Priorities for action

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Lifestyle factors associated with low risk of
cardiovascular disease and Type 2 diabetes

• Low body mass index less than 25 kg/m2
• Not currently smoking
• Light -moderate alcohol intake
• Moderate to vigorous physical activity averaging
  at least 30 minutes per day
• A Prudent diet

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Risk of coronary heart disease in low risk groups
Stampfer et al, NEJM, 2000
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Risk of type 2 diabetes in low risk groups
Hu et al, NEJM, 2001
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Low risk/protective factors defined in the Cork
Kerry Diabetes and Heart Disease Study

• WHR lt 0.85 in women and lt 0.90 in men
• BMI lt 25 Kg/m2
• Light drinkers
• Never smokers
• Physically active (moderate and vigorous physical
  activity)
• Prudent diet cluster

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Dietary clusters

• Traditional diet 57 of sample
• High SFA, MUFA, energy from fat, low PUFA, low
  PUFA/SFA ratio)
• Prudent diet 40 of sample
• High fibre, PUFA, PUFA/SFA ratio, Vits C D, low
  total fat, SFA, MUFA,cholesterol, energy from
  fat) 40
• Alcohol convenience food group 3 of sample

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Prevalence and clustering of protective factors
in Cork Kerry Study
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Blood pressure by number of protective factors
Diastolic BP
Systolic BP
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Means of metabolic variables by number of
protective factors
INSULIN
GLUCOSE
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Salt Intake and Blood Pressure

• Animal Genetic models
• Observation epidemiological studies, incl.
  Migrant studies
• RCTs in Hypertensives Normotensives
• RCTs in young and older people
• DASH Trial (feeding study)
• Community intervention trial

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Animal model of salt induced hypertension
A colony of 26 chimpanzees given a fruit and
vegetable diet of very low Na and high K intake
were maintained in long-standing, socially stable
small groups for three years. Half of them had
salt added progressively to their diet during 20
months. This addition of salt within the human
dietetic range caused a highly significant rise
in systolic, mean and diastolic blood pressure.
The change reversed completely by six months
after cessation of salt. Denton et al. Nat
Med. 1995 Oct1(10)1009-16
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Chimpanzees
Pre
Treatment Period
Post
6 month
14 month
20 month
3 month
6 month
150

140

130
120
Control n12
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Blood Pressure (mmHg)
100
90
80
Experimental n10
70
60

50
40
Plt0.05, Plt0.001 compared to control group
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DASH-Sodium Trial (All participants N412)
Salt intake (g/day)
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6
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Systolic BP (mmHg)
Control Diet
DASH Diet
Diastolic BP (mmHg)
Control Diet
DASH Diet
Urinary Sodium (mmol/24h)
Sacks et al. NEJM 2001 3443-10.
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The Main Determinants of Health
Dalhgren and Whitehead, 1991
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Major Determinants of Health in Ireland

• Social status, Income Education
• Environment (Social, cultural, physical,
  family)
• Infectious disease
• Behaviour (Diet, exercise, smoking, alcohol,
  risk taking behaviour)

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Burden of Disease
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TobaccoWorld-wide death toll

• 62 million dead since 1950 (WHO)
• 500 million alive today to die (World Bank)
• 1 in 2 smokers will die prematurely

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Age at which smokers start
US data 1991, Institute of Medicine
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Cigarette smoking by deprivation level in Great
Britain. Data from general household survey
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Survival by smoking status, according to study of
male British doctors (follow up after 40 years,
1951-91). Adapted from Doll et al (see Further
Reading box)
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Stages of worldwide tobacco epidemic
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Prevalence of overweight children aged around 10
years in Europe
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Prevalence of overweight in Irish children
(N18,000)
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Prevalence of obesity in Irish children
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Obesity Trends Among U.S. Adults between 1985 and
2002

• Definitions
• Obesity having a very high amount of body fat in
  relation to lean body mass, or Body Mass Index
  (BMI) of 30 or higher
• Body Mass Index (BMI) a measure of an adults
  weight in relation to his or her height,
  specifically the adults weight in kilograms
  divided by the square of his or her height in
  meters

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Obesity Trends Among U.S. AdultsBRFSS, 1991-2002
(BMI 30, or 30 lbs overweight for 5 4 woman)
2002
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1987
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1988
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1989
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs overweight for 5 4 woman)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs overweight for 5 4 woman)
(BMI ?30, or 30 lbs overweight for 54 person)
No Data lt10 1014
1519 2024 25
Source Behavioral Risk Factor Surveillance
System, CDC
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Historic, current and projected obesity
prevalence rates (BMI gt/ 30kg m-2) for the
United States, England and Wales, Mauritius,
Australia and Brazil from 1960 to 2025. Courtesy
of the International Obesity Task force.
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Prevalence of fibrous plaque lesions
in 204 children young adults by age
Berenson et al, NEJM, 1998
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Factors contributing to the Obesogenic
Environment
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The obesogenic environment Many people
believe that dealing with overweight and obesity
is a personal responsibility. To some degree they
are right, but it is also a community
responsibility. When there are no safe,
accessible places for children to play or adults
to walk, jog or ride a bike, that is a community
responsibility. When school lunchrooms or office
cafeterias do not provide healthy and appealing
food choices, that is a community responsibility.
When new or expectant mothers are not educated
about the benefits of breast-feeding, that is a
community responsibility. When we do not require
daily physical education in our schools, that is
also a community responsibility. The challenge is
to create a multi-faceted public health approach
capable of delivering long-term reductions in the
prevalence of overweight and obesity. This
approach should focus on health rather than
appearance, and empower both individuals and
communities to address barriers, reduce
stigmatization and move forward in addressing
overweight and obesity in a positive and
proactive fashion. - US Surgeon General, 2001
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Total Serum Cholesterol in North Karelia 1972-1997
FINRISK Study, Vartianen et al, IJE, 2000
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Political/ economic issues in relation to obesity

• Over production/ consumption in developed
  countries
• Commercial vested interests and
  pseudo-democracy
• Global hunger
• Agricultural subsidies 3rd World trade

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World Hunger

• 3 billion people live on less than 2/day.
• 2.6 billion without access to adequate sanitation
• 2 billion deprived of electricity
• 1 billion without adequate shelter
• 840 million malnourished
• 880 million without access to medical care

1998 Human Development Report, UN Development
Program
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National issues in relation to obesity

• Food quality
• Food labeling
• Marketing for children adults
• Schools, educational and sports sponsorship
• Physical inactivity promotion of computer games
• Low priority for play space in planning
• Barriers to exercise/ Car culture

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Priorities for action

• World class population health infrastructure
• Minister for Population Health
• Ring fence 1 of health budget for Population
  Health
• Cabinet sub-committee for Health Social
  inclusion (HIA)
• Horizan scanning for health (UK Wanless Report
  evidence based policy making)
• Education, education, education

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Population Health Targets

• Set, monitor and respond to targets on
• Obesity
• Diet (Fruit veg portions/day)
• Exercise
• Smoking
• Alcohol
• Mental health
• Quality of life

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Rudolf Ludwig Karl Virchow (1821-1902)the
Father of Social Medicine
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Virchows career

• A pathologist and medical school lecturer in
  Berlin
• Pioneer in establishing cell doctrine in
  pathology and effects of disease in the human
  body
• He coined the terms thrombus and embolus,
  leukocytosis and leukemia, amyloid and heme
  pigments, Virchows node, Virchows triad
• Discovered the pathophysiology of trichinosis,
  called for compulsory meat inspection in Germany
• Designed and supervised Berlin sewage system
• Never accepted the simple causal relationship
  between bacterium and disease (Koch)

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If disease is an expression of individual life
under favorable conditions, then epidemics must
be indicative of mass disturbances of mass life.
R. Virchow, Report on the Typhus Epidemic in
Upper Silesia, 1848
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• With one and a half million you cannot begin
  with palliatives, if you want to achieve anything
  you have to be radical.
• The task of any reasonable and democratic
  government will always be to educate the people
  and liberate them, not only materially but
  spiritually.
• The absolute separation of school and church is
  more necessary in Upper Silesia than anywhere.
• That is why I insist that free and unlimited
  democracy is the single most important principle.
  If we get free and well-educated people then we
  shall undoubtedly have healthy ones as well.

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The goal is to improve not only health status
but human development, which embraces equity,
solidarity, social justice, human rights, and
moral and ethical imperatives. The time has come
to herald human rights as both the foundation of
public health practice and the compass of public
policy actions
APHA statement Public health Human Rights
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To adopt human rights as the foundation of public
health practice, research, and policy in all
countriesTo make policymakers accountable for
decisions affecting human health and dignityTo
galvanize society's involvement in the prevention
of human suffering and the promotion of social
justice
Challenges for Public Health Professionals
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Medicine is a social science, and politics
nothing but medicine on a grand scale.
- R. Virchow, Die Medicinische Reform, 1848