1. Institut für Epidemiologie und Sozialmedizin der Universität Münster1
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 Prevention of Cardiovascular and Other Chronic Diseases

2. Growing of the world population1
Growing of the world population
According to the UN the world population reached 6 billion on October 12, 1999.
billion people
billion people
billion people
billion people
prognosis for billion people
122 years
34 years
39 years

3. 1

4. 1

5. 1
Source: Statistisches Bundesamt, Bundesinstitut für Bevölkerungsstudien

6. Population of Germany by age groups 1950–1998
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

7. 1

8. Life expectancy at birth for men in Europe1
Life expectancy at birth for men in Europe
1991 and 1998
Source: WHO – European health for all database (HFA-DB) – * 1997
years
EU average
Europe
Germany
77.0
74.6

9. Life expectancy at birth for women in Europe1
Life expectancy at birth for women in Europe
1991 and 1998
Source: WHO – European health for all database (HFA-DB) – * 1997
years
EU average
Europe
Germany
82.7
80.8

10. Figures are difference in years between West minus East1
Contribution to gap in life expectancy between central and eastern Europe and rest 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: 421–25

11. 1

12. Change in rank order of leading causes of death (world)1
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.

13. 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

14. Most frequent causes of death in Germany in 2000 (1)
Source: StBA, Statistisches Jahrbuch (2002)

15. Most frequent causes of death in Germany in 2000 (2)1
Most frequent causes of death in Germany in 2000 (2)
Source: StBA, Statistisches Jahrbuch (2002)

16. Prevalence of gross obesity (BMI 30)1
Prevalence of gross obesity (BMI 30)
German National Health Survey 1998 (n= 7124)
Men
Women
Source: Bergmann KE, Mensink GBM. Körpermaße und Übergewicht. Gesundheitswesen 1999; 61:S115–S120

17. Sports activity in hours per week by age groups1
Sports activity in hours per week by age groups
German National Health Survey 1998
West
East
Men
hours per week:
Source: Mensink GBM. Körperliche Aktivität. Gesundheitswesen 1999; 61:S128–S131

18. 1
Nutrition (diet)

19. 1
The contrasting distributions of serum cholesterol in South Japan and Eastern Finland
100
200
300
400
500 20 40 60 80
South Japan
Eastern Finland
Relative frequency (%)
Total serum cholesterol (mg/100 ml)
Source: Rose G. The strategy of preventive medicine. Oxford University Press; 1992

20. 1
Relative risks (95% CI) of CHD mortality per 20 mg/dL cholesterol 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

21. 25 year CHD mortality rates
25 year CHD mortality rates* in six cohorts of the Seven 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

22. Cretan Dietary Habits (six commandments) More bread1
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) oil margarine*, 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

23. 1
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§
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
Overall mortality 20
3.37
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

24. 1
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

25. 1
Indo-Mediterranean Diet Heart Study – a randomised single 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)
(%)
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

26. 1
Physical activity

27. 1
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 mortality in men and women. JAMA 1996; 276: 205–210

28. Physical activity improves health in the following ways: 1
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

29. Other documented health benefits include: 1
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

30. 1
Smoking – Non Smoking

31. 1
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
140 / 105
10 / 105
669 / 105
413 / 105
Source: Doll R, Peto R. Mortality in relation to smoking: 20 years' observations on male British doctors. BMJ 1976; 2: 1525–36

32. 1
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
Age
% Survivors
Never smoked regularly
33% 8%
80%
50%
Cigarette smokers:    
Source: Doll R, Peto R, Wheatley K et al. Mortality in relation to smoking. BMJ 1994; 309: 901–911

33. incidence rate (per 1000 py)
MONICA Augsburg Cohort Study 1984–1992
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 20 30 40 10
incidence rate (per 1000 py)
RR = 1.0
2.7
2.8
4.2
6.5
8.3
11.1
1.5 1
8 / 373
4 / 133
7 / 110
7 / 75
4 / 35
16 / 107
6 / 33
9 / 149
Risk factor
combination:
Actual Hypertension
TC/HDL-C  5.5
Smoking ( 1 cig./day)
Incident MIs /
Population at risk:
Arrows refer to synergism between smoking and hypercholesterolaemia
Source: Keil et al. Eur Heart J 1998

34. incidence rate (per 1000 py)
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 20 30 40 10
incidence rate (per 1000 py)
HRR = 1.0
2.7
2.8
4.2
6.5
8.3
11.1
1.5 1
0.0%
2.2%
7.2%
8.8%
5.6%
23.1%
9.0%
9.5%
Risk factor
combination:
Actual Hypertension
TC/HDL-C  5.5
Smoking (> 1 cig./day)
Population attributable fraction

35. Smoking-attributed numbers of deaths per year1
Smoking-attributed numbers of deaths per year
All ages, Germany 1955–1995
Males
Females
Annual smoking deaths
(1000s)
Source: Peto, Lopez et al. 1992, 1994

36. Smoking – Cancer, cardiovascular diseases, and life expectancy1
Smoking – Cancer, cardiovascular diseases, and life expectancy
Smoking has caused more cancer than medicine has even cured Richard Peto
Smoking reduces life expectancy by 8 years Richard Peto
Smoking is responsible for more deaths from cardiovascular diseases than from lung cancer Ulrich Keil

37. 1

38. What can we achieve with changes in diet and lifestyle?1
What can we achieve with changes in diet and lifestyle?

39. 1
Primary prevention of coronary heart disease in women through diet and lifestyle (1)
Prospective cohort study with data from the Nurse’s Health Study:
women, age 34–59 years, were followed from 1980–1994
During 14 years of follow-up 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

40. 1
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
Source: Stampfer MJ et al. N Engl J Med 2000; 343: 16–22

41. 1
Risk of coronary heart disease (CHD) in low-risk groups in the Nurses’ Health Study 1980–1994
Source: Stampfer MJ et al. N Engl J Med 2000; 343: 16–22

42. 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

45. N achdenken (to contemplate)1
Z uschauen (to watch)
E ntspannen (to relax)
N achdenken (to contemplate)

46. Der Mensch ist, was er isst.1
Der Mensch ist, was er isst.
Ludwig Feuerbach – 1872 8

47. Die größten Sünden werden in der Küche begangen1
Die größten Sünden werden in der Küche begangen
Friedrich Nietzsche – 1900 9

48. 1
Vogel fliegt
Fisch schwimmt
Mensch läuft
Emil Zátopek – 2000 8

49. 1
When the real causes have been removed, individual susceptibility ceases to matter
Geoffrey Rose
The Strategy of Preventive Medicine, 1992 9

50. 1
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 4

51. 1
Die Medizin ist eine soziale Wissenschaft und die Politik ist weiter nichts als eine Medizin im Großen.
Rudolf Virchow – 1902 10

52. 1
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 10

53. Anhang

54. 1
Percentage (%) of deaths (cancer, all causes) caused by smoking / of all deaths in 1000, in Germany 1990
Source: Peto, Lopez et al. 1992, 1994

55. The most frequent cancers as a percentage of all cancers Germany1998
Incident cases
Source: AG Bevölkerungsbezogener Krebsregister in Deutschland. Krebs in Deutschland. 3. Ausgabe, Saarbrücken, 2002, S. 9

56. 1
The most frequent hospital discharge diagnoses for male patients Germany 1999
Source: Statistisches Bundesamt. Gesundheitswesen. Fachserie 12, Reihe 1, 1999, S. 109

57. Early retirement (Berufs- und Erwerbsunfähigkeit) by cause and gender Germany 1999
Neoplasms
(ICD-9 140–208)
Cardiovascular diseases
(ICD-9 390–459)
Respiratory diseases
(ICD-9 460–519)
Accidents and poisonings
(ICD-9 800–999)
Source: Statistisches Bundesamt. Gesundheitswesen. Fachserie 12, Reihe 1, 1999, S. 159