Cardiovascular prevention in Germany Prof Dr Helmut Gohlke

„Cardiovascular prevention in Germany“ Prof. Dr. Helmut Gohlke Deutsche Herzstiftung

Coronary Mortality in Germany – Men Cases per 100 000 Inhabitants per year Great Britain Germany NL France………. Germany Coronary-Mortality in men in France: about 80/ 100. 000 in Germany : about 170/100. 000 France Great Britain source : Ge. Bu

Coronary Mortality in Germany – Women Cases per 100. 000 Inhab. per year Great Britain Quelle : Ge. Bu Germany NL France………. Coronary –mortality in women in Germany : about 90/ 100 000: i. e. the coronary mortality of French men is similar or less than that of German women , French women have a 50% lower coronary mortality compared to German women!

All Cause - and Cardiovascular Mortality in Germany per 100 000 Inhab. in 2004 Men • All Cause • 623 (542 -741) (BW-Sachs. Anhalt) • Coronary • cerebr. vasc. Dis. • Heart+Vascular. Diseases 149 52 201 32, 3% Women 342 (299 -414) (BW-Saarland) 81 44 125 36, 5%

Decrease of All Cause Mortality in Germany per 100 000 Inhab. from 2004 2010 Men + Women • All Cause 2004 • 468 (408 - 534) (BW-Sachsen-Anhalt) • All Cause 2010 • 420 (367 -487) • (-10, 3%) (BW-Sachsen-Anhalt) Cardiovascular diseases are the most important single cause for premature disability and death in Germany! They are largely preventable by primary-preventive measures.

Actual causes of Death in the US in 1990 und 2000 Poor diet and physical inactivity 000 300 Mokdad et al JAMA. 2004; 291: 1238 -1245 365 000 (15, 2)

The Mediterranean Diet and Mortality Olive Oil and Beyond Frank B. Hu NEJ M 2003; 348: 2599 -2608

N= 22, 043 adults N Engl J Med 2003; 348: 2599 -608.

Methods • Adherence to the traditional Mediterranean diet was assessed by a 10 -point Mediterranean-diet scale „traditional Mediterranean diet score (t. MED)“ * • that incorporated the salient characteristics of this diet *Trichopoulou et al NEJ M 2003; 348: 2599 -2608

Traditional Mediterranean Score • 9 components 0 to 9 Points (minimal to maximal adherence). • 1 point each for above average gender adjusted consumption of „healthy“ components: – Vegetables [incl. potatoes], – Fruits and nuts, – Legumes, – Cereals, – Fish, and – Ratio of monounsaturated/saturated fats 1 Point each for below average gender adjusted consumption of„unhealthy“ components: - Dairy products and - Meat. additionally 1 point für - Alcohol consumption of 5 -25 g/d for women; 10 -50 g/d für men *Trichopoulou et al NEJ M 2003; 348: 2599 -2608

N= 22, 043 adults During 44 months of follow-up, there were 275 deaths Relative Risk of Death with 2 -Point - Increase of the Score -25% -33% -24% N Engl J Med 2003; 348: 2599 -608.

74 607 participants Follow Up 89 months * BMJ, Apr 2005; 330: 991 -997 * European Prospective Investigation into Cancer and Nutrition (EPIC),

AARP = (American Association of Retired Persons) 214 284 men and 166 012 women = 380 296 persons ~ 1. 9 Mio person-years Arch Intern Med. 2007; 167(22): 2461 -2468

Alternative vs Traditional Mediterranean Score • 9 components 0 to 9 Points (minimal to maximal adherence). • 1 point each for above average gender adjusted consumption of „healthy“ components: – Vegetables [incl. potatoes], – Fruits and nuts, Separates fruits and nuts in two groups – Legumes, Counts only whole grain products – Cereals, – Fish, and – Ratio of monounsaturated/saturated fats 1 Point each for below average gender adjusted consumption of„unhealthy“ components: - Dairy products and Eliminates dairy products - Meat. Counts only red and processed meat (beef-, pork-, organ additionally 1 point für meats, luncheon meats) - Alcohol consumption of 5 -25 g/d for women; 10 -50 g/d für men same alcohol range for both men and women (5 -25 g/d) *Trichopoulou et al NEJ M 2003; 348: 2599 -2608

Mediterranean Dietary Pattern (a. MED) and cause-specific Mortality Multivariate Rel Risk in 214. 284 men Score-Points 0 -3 4 -5 6 -9 p -17 -23% • CV-Disease 1 • Cancer 1 • Other causes 1 0. 95 (. 86 -1. 04) 0. 78 (. 69 -. 87) 0. 86 (. 80 -. 93) 0. 83 (. 76 -. 91) 0. 90 (. 81 -1. 00) 0. 77 (. 70 -. 88) Mitrou et al Arch Intern Med. 2007; 167(22): 2461 -2468 . 001

Mediterranean Dietary Pattern (a. MED) and cause-specific mortality Multivariate Rel Risk in 166 012 women Score-points 0 -3 4 -5 6 -9 p -19 -28% • CV-Disease • Cancer • Other causes 1 1 1 0. 85 0. 93 0. 82 0. 81 0. 88 0. 72 Mitrou et al Arch Intern Med. 2007; 167(22): 2461 -2468 . 01. 04. 001

74 886 women, 38 - 63 yrs, Nurses’Health Study, No CAD or DM : follow up from 1984 – 2004. Alternate mediterranean diet score according a validated self reported food frequency questionnaire - 6 times between 1984 and 2002. Circulation. 2009; 119: 1093 -1100

Age Standardized Baseline Characteristics According to Quintiles of the alternativen Mediterranen Score of 1984 1, 1 2, 5 0, 8 4 3 2, 5 2, 4 5 Fung et al Circulation. 2009; 119: 1093 -1100 Q 5/Q 1

Multivariate Relative Risk of CVD (combined CHD and stroke) by quintiles of the alternativen Mediterranen Score of 1984 Fung et al Circulation. 2009; 119: 1093 -1100

Multivariate Relative Risk of fatal CVD (combined CHD and stroke) by quintiles of the altern. Mediterr. Score of 1984 P < 0. 0001 Fung et al Circulation. 2009; 119: 1093 -1100

Recent Advances in Preventive Cardiology and Lifestyle Medicine Components of a Cardioprotective Diet New Insights Dariush Mozaffarian, MD, Dr. PH; Lawrence J. Appel, MD, MPH; Linda Van Horn, Ph. D, RD Mozaffarian et al Circulation. 2011; 123: 2870 -2891

Fruits Vegetables Whole Grains Nuts Fish Unprocessed meat Processed meat Milk/Dairy Eggs Mozaffarian, D. et al. Circulation 2011; 123: 2870 -2891 Relationships of consumption of different foods with incidence of coronary heart disease (CHD), stroke, and diabetes in meta-analyses of prospective cohort studies (PCs)

Mozaffarian et al Circulation. 2011; 123: 2870 -2891

The Role of Nutrition and Overweight for High Blood Pressure High sodium, high calories Increased sympathetic acticity and stress ! …. induce loss of aortic elasticity High Na-levels activate Angiotensin II in heart and vessels and. . Increased blood pressure! Increased sympathic activity increased cardiac output Increased filtration and salt retention Abdominal fat produces substances to increase stiffness of conduit vessels , sympathetic activity and angiotensin II levels.

The Role of Nutrition and Weight Loss for Blood Pressure Lowering Low salt, normal calories Weight reduction reduces sympathetic activity BP goes down sinkt! Weight reduction, low Na. Cl, and healthy diet improve elasticity of the large arteries … Healthy diet, improved renal Na excretion! …. and also of the small arteries Less visceral fat, less vasoactive substances, less sympathetic activity

Impact of a Healthy Diet on Blood Pressure - The DASH- Diet - DASH-Diet to lower Blood Pressure (Dietary Approaches to Stop Hypertension) favours compared to a typical US-Diet : Fruits, vegetables, low fat dairy products, wholegrain products, poultry, fish , nuts, fibers, protein ; Contains more : Potassium, Calcium, Magnesium But less: Red meat, sweets, soft-drinks, total fat, saturated fats, cholesterol Corresponds largely to the concept of the mediterranean diet. Sacks ! et al N Engl J Med 2001; 344: 3 -10. )

Impact of a Healthy Diet on Blood Pressure - The DASH- Diet - - 8 mm. Hg DASH Diät - 1, 6 mm. Hg - 5, 1 mm. Hg Lower sodium DASH vs higher-sodium control: -15 mm. Hg ! Dietary Sodium Dietary. Salt High: 9 g Intermediate: 6 g Low : 3 g Sacks et al N Engl J Med 2001; 344: 3 -10. )

N Engl J Med 2010; 362: 590 -9.

Projected Annual Reductions in Cardiovascular Events Given a Dietary Salt Reduction of 3 g per Day in Nonblack Men, and Nonblack Women, According to Age Group. Nonblack Men Women Bibbins-Domingo et al N Engl J Med 2010; 362: 590 -9.

Projected Annual Reductions in Cardiovascular Events Given a Dietary Salt Reduction of 3 g per Day in Nonblack Men, and Nonblack Women, According to Age Group. Nonblack Men Women Conclusions Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target. Bibbins-Domingo et al N Engl J Med 2010; 362: 590 -9.

Competition 5 th century b. C.

A prospective cohort study of 416 175 individuals (199 265 men and 216 910 women) The Lancet, Vol. 378: 1244 -1253 Oct 01, 2011

Hazard ratio Wen et al The Lancet, Vol. 378 : 1244 -1253; 2011 Relative Risk for cardiovascular Disease in Relation to Activity Level compared to inactive Persons Those in the low-volume activity group, who exercised for an average of 92 min per week or 15 min a day, had a 14% reduced risk of all-cause mortality, and had a 3 year longer life expectancy. Every additional 15 min of daily exercise beyond the minimum amount of 15 min/day further reduced all-cause mortality by 4% and all-cancer mortality by 1%. Inaktive Low Medium Activity level High Very high

Cardiovascular Disease Mortality All Cancer Mortality Diabetes Mortality Wen et al The Lancet, Vol. 378 : 1244 -1253; 2011 All Cause Mortality

Population based cohort study with follow-up over 35 years. Setting Municipality of Uppsala, Sweden. Participants 2205 men aged 50 in 1970 -3 who were reexamined at ages 60, 77, and 82 years. Main outcome measure: Total (all cause) mortality. No loss to Follow up!!! Byberg et al BMJ 2009; 338: b 688

Byberg et al BMJ 2009; 338: b 688 Cumulative Total Mortality after age 50 in Relation to Leisure Time Physical Activity (PA) Mortality 81. 4% low PA 72. 0% med PA 61. 8% high PA

Byberg et al BMJ 2009; 338: b 688 Cumulative mortality from age 60 (Kaplan-Meier) according to changes in leisure time physical activity level at age 50 and total mortality.

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Indicators of Prevention Other countries with a Score <13 in Prevention: Bulgaria(12), Czechia(11), Lituenia, Poland, Rumania

Summary and Conclusion Although there has been - a reduction in cardiovascular and total mortality and - an improvement in life expectancy (3 months per year) over the last 50 years in Germany, there is still room for improvement in the arena of prevention compared to our neighbour France: Improved calorie adjusted nutrition (more fruits and vegetables, less salt) More physical activity - and not to forget: More stringent laws against smoking in public places, More incentives for prevention ! n o i t n e t at r u o y r improve the health status of are the actions that could substantially o f u the general population o - without increasing costs of the health care y k system. n a h t I