cardiovascular diseases and blood lipids€¦ · david faeh: cardiovascular diseases and blood...

1

C

Master of Advanced Studies in Nutrition and Health HS 2009

Cardiovascular Diseases and Blood Lipids

Universität ZürichInstitut für Sozial- und Präventivmedizin

David Faeh

Aims

• CVD, CHD, Stroke

• Morbidity, Mortality, Lethality

• Prevalence, Incidence

• Blood lipids: What is it? How influenced?

• How are blood lipids related with CVD?

Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009

How are blood lipids related with CVD?

• Risk and protective factors

• Lifestyle recommendations

2

Proportion of causes of death: Age standardized death rates per 100,000, Switzerland

1%

20%

Groups of causes of death 2007, Men

30%

33%

7%

9%

20%


Source: Bundesamt für Statistik, 2007

Infectious disease Cancer Cardiovascular Respiratory Injury Others

Proportion of causes of death: Age standardized death rates per 100,000, Switzerland

1%

Groups of causes of death 2007, Women

29%

33%

5%

6%

26%




3

Proportion of years of life lost (1-70y) by cause of death: Age standardized rates per 100,000, CH

2%

19%

YLL by group of cause of death 2007, Men

28%

17%

2%

32%

19%

17% = 20 540 YYL or




Number of years of life lost (YLL) due to CVD: years that people loose because they die before 70

17% = 20,540 YYL or 558 YLL / 100,000 inhabitants

Proportion of years of life lost (1-70y) by cause of death: Age standardized rates per 100,000, CH

2%

21%

YLL by group of cause of death 2007, Women

44%

11%

20%

21%



2%


Number of years of life lost (YLL) due to CVD: years that people loose because they die before 70

11% = 7,335 YLL or 202 YLL / 100,000 inhabitants

4

175

200

225

Cardiovascular disease (CVD): cave definitionem!

standardisierte Sterberaten, Schweiz 2005

Sterbefälle pro 100‘000

Personenjahre

Subsumed causes of death

50

75

100

125

150

175

andere Herzkrankheiten

zerebrovaskuläre Krankheiten

Hypertonie

übrige Herz-Kreislauf-Krankh.

z.B.: Aneurysma, Thrombose, Phlebitis, Varizzen

z.B.: Myo-& Pericarditis,


0

25

Männer Frauen

KHK

mb 2007Datenquelle: Todesursachenstatistik (BFS)

Klappen- und Herzinsuff.

Cardiovascular disease (CVD)

Mortality Morbidity

Death: Disease:


Death:Can be assessed only once „Tip of the iceberg“

Disease:Is always higher than mortality. Can occur numerous times in one individual

5

Mortality Morbidity

„Film“:Number of…

„Photo“:Number of

„Incidence“ PrevalenceIncidence


Number of… •…death cases (mortality) or •…new diseases (morbidity) per number of persons under risk (100‘000) and during a certain time span (1 year)

persons that have a disease at a specific point of time (in %)

Myocardial infarction (GB, 60 Mio inhabitants in 2003)

Morbidity of CVD: UK, CDN

•260´000 new cases per year (incidence)

•1.4 Mio live with the consequences (prevalence)

Cerebrovascular disease (Canada, 32 Mio, 2003)


• 50´000 new cases per year (incidence)

•300´000 live with the consequences (prevalence)

Sources: British Heart Foundation & Heart and Stroke Foundation of Canada

6

•60´000 cases of myocardial infarction,

Morbidity of CVD, Switzerland

stroke and cardiac arrest per year

•30-40% without specific warning signs


Source: Switzerlanderische Herzstiftung

•2005: Globally 17.5 Mio death cases / year

Mortality of CVD, globally

– 30% of all death cases

– 7.6 Mio † coronary heart disease (CHD)

– 5.7 Mio † cerebrovascular disease

C f


•2010: CVD = Main cause of death in developing countries

Source: World Health Organization WHO, 2005, http://www.who.int

7

• 2005: 23´000 death cases per yearAb t 38% f ll i t d d th

Mortality of CVD, Switzerland

– About 38% of all registered death cases

– 9´400 † coronary heart disease (CHD)

– 4´100 † cerebrovascular disease

• German CH > Ticino & French CH, Men > Women


• Social gradient (inequality)

• 86.5% (M) und 97% (W) of death cases occur after

age 65 (2005)Source: Bundesamt für Statistik, 2005

Sterbefälle pro 100‘000 Einwohner und Jahr (WHO-Standard- bevölkerung „Europa“)

160

180

200

KHK: Rohraten , Schweiz 1969-2003

Männer

CHD: Crude ratesDeath cases per 100‘000 inhabitantsper year

Men

60

80

100

120

140

Frauen

RohratenCrude rates

Women

Men


ICD-10

Jahr

0

20

40

1970 1975 1980 1985 1990 1995 2000 2005ISPM Zürich, M. Bopp 2006Year

David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009

8

Sterbefälle pro 100‘000 Einwohner und Jahr (WHO-Standard- bevölkerung „Europa“)

160

180

200

KHK: Rohraten vs. standardisierte Raten, Schweiz 1969-200

Männer

CHD: Crude rates vs. age standardized ratesDeath cases per 100‘000 inhabitantsand year (WHO standard population)

Men

60

80

100

120

140

Frauen

Rohraten

standardisierte Raten

Crude rates

Age standardizedrates

Men

Women


ICD-10

Jahr

0

20

40

1970 1975 1980 1985 1990 1995 2000 2005ISPM Zürich, M. Bopp 2006Year


3.5

4

Geschlechterquotient in der Herz-Kreislauf-Mortalität Schweiz 2001/05

Sex-ratio (men vs. women) in CVD-mortality(Switzerland 2001/05)

1.5

2

2.5

3


1

Alter40-44 50-54 60-64 70-74 80-84 90-9445-49 55-59 65-69 75-79 85-89 95+

mb 2007Datenquelle: Todesursachenstatistik (BFS)


Age

9

CHD and stroke mortality: German vs. French CH

1

French Switzerland : German Switzerland

e)

MenRa

tio (l

og

. sca

le

Higher mortality in German-speaking areas

Women


0.1

CH

D

Str

oke

CH

D

Str

oke

Source: Faeh et al, JECH 2009 Aug;63(8):639-45

Data: Swiss National Cohort 2000

1

French Switzerland : German Switzerland

France : Germany

e)

CHD and stroke mortality: German vs. French areas

MenRa

tio (l

og

. sca

le

Higher mortality in German-speaking areas

Women


0.1

CH

D

Str

oke

CH

D

Str

oke

Source: Faeh et al, JECH 2009 Aug;63(8):639-45

Data: Swiss National Cohort, 2000Mortality database WHO, 2000

10

50

60 German Switzerland

French SwitzerlandMen

10

20

30

40

Pre

vale

nce

(%)

Pre

vale

nce

(%)


0

Less-than-good health

Current smoking Daily alcohol consumption

Inf requent f ruit consumption

Physical inactivity Obesity

Data: Swiss Health Survey 1992/93

50

60 German Switzerland

French SwitzerlandWomen

10

20

30

40

Pre

vale

nce

(%)

Pre

vale

nce

(%)


0

Less-than-good health

Current smoking Daily alcohol consumption

Infrequent f ruit consumption

Physical inactivity Obesity

Data: Swiss Health Survey 1992/93

11

Educational inequality in German Switzerland

300

400

500

600

low

middle

high

100,000 personyears Educational levelMen

0

100

200

All CVD CHD Stroke

Mortality/ 1

150

200

250

low

middle

hi h

Educational level

00 personyears Women


0

50

100

All CVD CHD Stroke

high

Mortality/ 100,00

Source: Faeh et al, BMC PH, in press

Data: Swiss National Cohort 2000

Estland

Koronare Herzkrankheiten (I20-I25)

Sterbefälle pro 100‘000 Einwohner, standardisiert auf WHO-Alterstruktur „Europa“

Herz-Kreislauf-Mortalität international um 2002

EstlandUngarn

TschechienÖsterreichDeutschlandUSAFinnlandSchottland

SchwedenNorwegenDänemarkNiederlandeEngland&WalesKanadaAustralien

Männer Frauen


10002000300040005000600070008000

ItalienSchweizSpanien

FrankreichJapan

0 1000 2000 3000 4000

Datenquellen: WHO, World Mortality Database / BFS, Todesfälle und Todesursachen (D,S,N,AUS,I,E:2001; USA,DK,NL,CDN,F,JAP: 2000; Italien nach ICD-9) M.Bopp, 2005

12

Estland


übrige Kardiopathien (I26-I51)



EstlandUngarn

TschechienÖsterreichDeutschlandUSA

FinnlandSchottland

SchwedenNorwegenDänemarkNiederlandeEngland&Wales

KanadaAustralien

Männer Frauen


10002000300040005000600070008000


FrankreichJapan

0 1000 2000 3000 4000


Estland



zerebrovaskuläre Krankheiten (I60-I69)



EstlandUngarn

TschechienÖsterreichDeutschland

USAFinnland

SchottlandSchwedenNorwegenDänemark

NiederlandeEngland&Wales

KanadaAustralien

Männer Frauen


10002000300040005000600070008000


FrankreichJapan

0 1000 2000 3000 4000


13

Estland



zerebrovaskuläre Krankheiten (I60-I69)

übrige Herz-Kreislauf-Krankheiten (Rest Kap. I)



EstlandUngarn

TschechienÖsterreichDeutschland

USAFinnland

SchottlandSchwedenNorwegenDänemark

NiederlandeEngland&Wales

KanadaAustralien

Männer Frauen


10002000300040005000600070008000


FrankreichJapan

0 1000 2000 3000 4000


Lethality

•Death cases per 100 disease cases•Death cases per 100 disease cases

with the same disease

•Tells us how hazardous a disease is in


terms of risk of dying

14

Relationship morbidity, mortality, lethality

Morbidity* Mortality** Lethality***Morbidity Mortality Lethality

Men 356 141 39.6%

Women 109 43 39.4%


Source: MONICA/KORA-Herzinfarktregister, Augsburg 2001-2003

*All myocardial infarction events (age standardized rates per 100´000)**Mortal myocardial infarction events***Mortality / Morbidity x 100

Lethality of myocardial infarction (MI) & sudden cardiac death (SCD), 25-74 y

• 12% die on the first day after hospitalisation ( 29% f ll d th )(= 29% of all death cases)

• 5.5% die on day 2 - 28 after hospitalisation (= 12% of all death cases)


Source: MONICA/KORA-Herzinfarktregister Augsburg 2001-2003

• 24% die, before they could be hospitalized (= 59% of all death cases)

15

Sudden cardiac deaths (SCD) vs. surviving (24h) myocardial infarction (MI)-patients (25–74y)

Known disease SCD MI

High blood pressure 65% 65%

High cholesterol levels 40% 60%

Diabetes 35% 30%


Source: Dtsch Med Wochenschr 127(44): 2311-6

Coronary heart disease 65% 30%

None 25% 25%

T t l h l t l (TC)

Blood lipids

•Total cholesterol (TC)

•High Density Lipoprotein Cholesterol (HDL-C)

•Low Density Lipoprotein Cholesterol (LDL-C)

•Triglycerides (TG)


16



17



18



19



20



21



22



23

Factors influencing blood lipids

•Age

•Sex

•Genetic background

•Body weight

•Diabetes


•Smoking

•Other lifestyles (diet, physical activity)

LDL-Cholesterol According to Age and BMI

LDL-cholesterol (mg/dl)

125

150

175

BMI > 30.0 kg/m2

BMI 27.6-30.0 kg/m2


75

100

16-25 26-35 36-45 46-55 56-65Age (years) Women (n=7,307)

gBMI 25.1-27.5 kg/m2

BMI 20.1-25.0 kg/m2

BMI 20.0 kg/m2

Source: PROCAM (Münster Heart Study)

24

HDL-Cholesterol According to Age and BMI

HDL-cholesterol (mg/dl)

50

60

70

BMI 20.0 kg/m2

BMI 20 1-25 0 kg/m2


30

40

16-25 26-35 36-45 46-55 56-65Age (years) Women (n=7,328)

BMI 20.1-25.0 kg/mBMI 25.1-27.5 kg/m2

BMI 27.6-30.0 kg/m2

BMI > 30.0 kg/m2


Triglycerides According to Age and BMI

Triglycerides (median, mg/dl)

100

125

150

175

200

BMI >30.0 kg/m2

BMI 27.6-30.0 kg/m2


50

75

100

16-25 26-35 36-45 46-55 56-65Age (years) Men (n=16,288)

BMI 25.1-27.5 kg/m2

BMI 20.1-25.0 kg/m2

BMI 20.0 kg/m2


25

Prevalence of Risk Factors in Men by HDL-C

HDL-C < 35 mg/dl

(n=1003)

35 mg/dl

(n=5698)

p

Cigarette smoking

Diabetes mellitus

BMI > 30 kg/m2

Triglycerides > 200 mg/dl

Hypertension

Famil histor of MI

44.7

11.2

18.7

42.2

29.5

18 0

29.8

6.7

8.5

15.3

26.5

16 1

< 0.001

< 0.001

< 0.001

< 0.001

< 0.05

n s


Family history of MI

LDL cholesterol > 160 mg/dl

MI incidence (in 10 years)

18.0

32.5

11.9

16.1

34.0

5.1

n.s.

n.s.

< 0.001



Relationship of blood lipidswith CVD

Depending onDepending on…

•Age

•Sex

•Smoking status


•Body weight

•Blood glucose

•Relationship of blood lipids

26

382

Incidence of Coronary Events According toHDL-Cholesterol and total Cholesterol

200-249

250-300

> 300

151118227

7438129

361653

100

200

300

400Incidence of coronary eventsper 1,000 in 8 years


< 35 35-55 > 55

< 200

200 24921

60

258 coronary events in 4,639

men, aged 40 to 65 years

TotalCholesterol (mg/dl)

HDL-Cholesterol (mg/dl)



15 20Prevalence (%)

Incidence of coronary events in 8 years of follow-up (%)

Distribution of Cholesterol to HDL-Cholesterol Ratio and Incidence of Coronary Events

5

10

5

10

15


00 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5

0

258 coronary events in 4,639 men (40-65 y)Total Cholesterol to HDL-Cholesterol Ratio


27

Normal fasting glucose(n=5679, 297 events)

Impaired fasting glucose ordiabetes mellitus (n=1022, 107 events)

Incidence of Coronary Events According to HDL- & LDL Cholesterol and Glycemic State

Incidence per 1.000in 10 years

Incidence per 1.000in 10 years

1

33

72

144

26 3783

50

100

150

200

in 10 years in 10 years

1

111

147175

5059

154

40

125

50

100

150

200


1 2 3

3

226 26 60

0

50

Tertiles ofHDL cholesterol Tertiles of

LDL cholesterol

Tertiles ofHDL cholesterol Tertiles of

LDL cholesterol

1 2 3

3

22340

0

50


Lifestyle and blood lipids

• Risk factors– Carbohydrates (fructose, glucose)

– Saturated and trans-fat

– Obesity

• Protective factorsUnsaturated fat


– Unsaturated fat

– Fibres

– Physical activity

28


1 2

1.4

1.6

/l)

†

Effect of dietary fructose on fasting triglycerides

0.2

0.4

0.6

0.8

1

1.2

Tri

gly

ceri

des

(m

mo

l/

* *

‡


white bar: controlgreen bar: fish oilred bar: high-fructosestriped red and green bar: fish oil & high-fructose

0

Source: Faeh et al, Diabetes. 2005 Jul;54(7):1907-13.

29

Increase in triglycerides byfructose-induced DNL

NEFANEFA

5Adipose Adipose tissuetissue

TGTG

FAFA

GlucoseGlucose

2

1

34

GlycogenGlycogen


FructoseFructose

VLDLVLDLTGTG

GlucoseGlucose

Source: Faeh et al, Diabetes. 2005 Jul;54(7):1907-13.

DNL: De Novo Lipogenesis

Metaanalysis: Dose-dependenthypotriglyceridemic effect of omega-3 fatty acids.


Source: Proc Nutr Soc 1999;58(2):397–401

30

Low-carbohydrate vs. high-carbohydrate diets


Source: Nutr Metab (Lond) 2005;2:31

Predicted Changes in Serum Lipids and LipoproteinsUse of dietary fats:


Source: Hu et al, JAMA 2002;288:2569-2578

31

Changes by Diet Group during the Maximum Weight-Loss Phase (1 to 6 Months) and the Weight-Loss Maintenance Phase (7 to 24 Months) of the 2-Year Intervention


Source: Shai et al, N Engl J Med. 2008 Jul 17;359(3):229-41

Risk of mortality from CVD associated with two point increase in adherence score for Mediterranean diet


Source: Sofi et al. BMJ 2008;337:a1344

Squares represent effect size; extended lines show 95% confidence intervals; diamond represents total effect size

32

0.02

TotalCholesterol

LDL-C TG HDL-C(weightstable)

HDL-C(activelylosing)

Plasma Lipids Improve with Weight Loss Meta-analysis of 70 Clinical Trials

ss 0 5

-0 04

-0.02

0.00

) g)

ol/L

kg

of W

eigh

t Lo

s m

g/dL per kg of W**

**

0.5

0.0

-0.5

-1.0

1 5


-0.06

0.04

m

mo

LDL-C=low density lipoprotein cholesterol; HDL-C=high-density lipoprotein cholesterol; TG=triglyceridesSource: Dattilo et al. Am J Clin Nutr 1992;56:320.

*P<0.05.

Weight Loss

*-1.5

-2.0

-2.5

8

16

24

Effects of Exercise Level and Intensity on LDL and HDL Particles in Overweight/Obese Men

l LD

Ll (

mg/

dL)

34567

oles

tero

l dL

)

P=0.015

-16

-8

0

S

mal

lC

hole

ster

o

0.0

0.4

-2-10123

H

DL

Cho

(mg/

d

L D

iam

eter

(n

m)

2

4

6

8

arge

HD

L te

rol (

mg/

dL)

P=0.03P=0.015 P=0.002

P=0.05

P=0.016


Source: Kraus et al. N Engl J Med. 2002;347:1483-1492.

Control HighAmountModerateIntensity

-0.4Low

AmountHigh

Intensity

LowAmountModerateIntensity

LD

L

Control High AmountModerateIntensity

-2

0

2

LowAmount

HighIntensity

LowAmount

HighIntensity

La

Cho

lest

33

Indication for drug therapy

Women Pre-Men, Women Post- Lipid Criteria

Primary prevention

MenopausalPost-Menopausal

Lipid Criteria

Other Riskfactors*

Other Riskfactors*

TCmmol/l (mg/dl)

TC / HDL-C

LDL-Cmmol/l (mg/dl)

0 or 1 0 >8.0 (309) >6.5 >5.0 (194)


( ) ( )

2 1 >6.5 (252) >5.0 >4.0 (155)

* Risk factors: 1. Family history of CHD; 2. Age (Men > 50y / women > 60 y); 3. Smoking; 4. Hypertension; 5. (Central) Obesity ( BMI >30 kg/m2), central; Hypertriglyceridemia >2,0mmol / l (175mg/dl ); Physical inactivity


34

Recommendations

• DASH: Dietary Approaches to Stop HypertensionHypertension

• TLC: Therapeutic Lifestyle Changes

• VLCD: Very Low Carbohydrate Diet


VLCD: Very Low Carbohydrate Diet

• Mediterranean diet


Nutrient Composition of TLC Diet

Nutrient Recommended Intake

• Saturated fat Less than 7% of total caloriesSaturated fat Less than 7% of total calories

• Polyunsaturated fat Up to 10% of total calories

• Monounsaturated fat Up to 20% of total calories

• Total fat 25–35% of total calories

• Carbohydrate 50–60% of total calories

• Fiber 20–30 grams per day

• Protein Approximately 15% of total calories


• Cholesterol Less than 200 mg/day

• Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain

Source: ATP III Guidelines, Therapeutic Lifestyle Changes (TLC)


35

Eating Pattern DASH TLC

Grains 6–8 sv/d 7 sv/d

Examples of daily dietary patterns consistent withAHA-recommended dietary goals at 2000 calories

Vegetables 4–5 sv/d 5 sv/d

Fruits 4–5 sv/d 4 sv/d

Fat-free or low-fat dairy products

2–3 sv/d 2–3 sv/d

Lean meats, poultry and fish <6oz./d ≤5 oz./d

Nuts seeds legumes 4–5 sv/wkCounted in


Source: Endocrinol Metab Clin North Am. 2009 Mar;38(1):45-78

Nuts, seeds, legumes 4–5 sv/wkvegetable servings

Fats and oils 2–3 sv/dAmount depends on calorie level

Sweets and added sugars 5 or less sv/wk No recommendation

AHA, American Heart Association; DASH, dietary approaches to stop hypertension; TLC, Therapeutic Lifestyle Changes; sv, serving.

Summary of nutrition guidelines for dyslipidemiatreatment derived from a metanalysis

1. Mediterranean and portfolio diets are recommended.

2. Reduce saturated fats to about 10% of total fat intake.

3. Eliminate trans fats.

4. Increase monounsaturated fats to 40% of total fat intake.

5. Increase polyunsaturated fats (ω-3 fats) to 40%-50% of total fat intake.

6. Increase viscous fiber to 50 g/d.

7. Increase vegetables to 6 servings per day.

8. Increase fruits to 4 servings per day.

9. Add plant sterols and nuts to diet.


10.Reduce refined carbohydrates and use low glycemic foods. Use more complex carbohydrates.

11.Consume high quality protein with cold water fish and organic lean meat and poultry.

12.Maintain ideal body weight and body composition.

Source: Prog Cardiovasc Dis. 2009 Sep-Oct;52(2):61-94

36

1. An abundance of plant foods (eg, fruits, vegetables, potatoes,

breads, grains, beans, nuts, and seeds)

Mediterranean Diet

2. Minimally processed and seasonally fresh foods

3. Fresh fruits as the typical daily dessert

4. Olive oil as the principal source of dietary fat

5. Dairy, poultry, and fish in low to moderate amounts

6. Less than five eggs per week



7. Red meat in low frequency and amounts

8. Wine in low to moderate amounts (one to two glasses per day for

men and one glass per day for women)

Al h li 1 19 Al h li 20 Al h li

Adjusted odds ratio for prevalence in 8,125 subjects fromNHANES III by increasing quantities of alcohol consumption

< AlcoholicDrink/Month

1–19 AlcoholicDrinks/Month

≥20 AlcoholicDrinks/Month

Low serum HDL-Cb 1.0 0.69 (0.60–0.78) 0.22 (0.16–0.29)

Elevated triglyceridesc 1.0 0.73 (0.62–0.87) 0.56 (0.43–0.74)


Source: Diabetes Care 2004;27(12):2954–9

37

Dietary Component Dietary Change LDL-C Reduction

Major

Approximate and cumulative LDL-C reductionachievable by dietary modification

j

Saturated fat <7% of calories 8%–10%

Dietary cholesterol <200 mg/d 3%–5%

Weight reduction Lose 10 lbs (4.5 kg) 5%–8%

Other LDL-lowering options

Viscous fiber 5–10 g/d 3%–5%



Viscous fiber 5 10 g/d 3% 5%

Plant sterol/stanol esters 2 g/d 6%–15%

Cumulative estimate 20%–30%

1. γ-/δ-Tocotrienols: 200 mg per night with food.2. Pantethine: 300 mg 3 times per day (or 450 mg 2 times a day).

Recommondations for nutritional supplements for improvement of blood lipids

g p y ( g y)3. ω-3 Fatty Acids: at 3 to 5 g/d at a ratio of 3 parts EPA, 2 parts DHA, and

gamma Linoleic acid (GLA) at 75% to 90% of the total DHA and EPA. Vitamin E at 100 IU/d with mostly γ-/δ-tocopherol (80%) should be added to reduce oxidative stress.

4. Niacin (nicotinic acid): various forms at 500 to 3000 mg/d.5. Red yeast rice (high quality and standardized): 2400 mg per night. Doses

of 4800 mg may be safe and even more effective.6. Probiotics: standardized to provide the optimal bacterial count.

C i 00 /d


7. Curcumin: 500 mg/d.8. Green tea extract: standardized to 250 to 500 mg of EGCG twice per day.9. Plant Sterols: 1.6 to 3.0 g/d in divided doses with food.

Source: Prog Cardiovasc Dis. 2009 Sep-Oct;52(2):61-94

38

Take-Home-Messages

• CVD mortality is decreasing in Switzerland b t CVD till j f d thbut CVD are still a major cause of death

• In contrast, CVD are increasing in developing countries


• Unfavourable blood lipid profile is a major risk factor for CVD


Take-Home-Messages (cont.)

• Blood lipids should be interpreted i di id ll d i th t t f thindividually and in the context of other CVD risk factors

• Besides age and sex, lifestyle factors strongly influence blood lipids


• An unfavorable blood lipid profile can substantially be improved with lifestyle changes and this decreases CVD risk


39

Take-Home-Messages (cont.)

Lifestyle changes include

1 K i h lth b d i ht1. Keeping a healthy body weight

2. Replace saturated by unsaturated FA

3. Choose plant instead of animal products

4. Avoid simple sugar, particularly fructose


5. Increase fibre intake

6. Consume alcohol in moderation

7. Avoid smoking


Also very important:

• Physical activity, but…


40

…be precise with your recommendations…



41

Thank youfor your attention



42

Risk Scores

• Framingham• PROCAM• PROCAM• SCORE• FINRISC• …


PROCAM Score

LDL-Cholesterin (mg/dl)

100 0101-105 1106-110 2111-115 3

HDL-Cholesterin (mg/dl)

35 1136-37 1038-39 940-41 8

Systolischer Blutdruck(mmHg)

<110 0100-119 1120-129 2

Alter (Jahre)

35-65 Alter-35

116-120 4121-125 5126-130 6 131-135 7136-140 8141-145 9146-150 10151-155 11156-160 12161-165 13166-170 14

42-43 744-45 646-47 548-49 450-51 352-53 254-55 1>55 0

Zigarettenrauchen

Nie 0Früher 2Zur Zeit 9

Nüchternblutzucker(mg/dl)

<120 0120 3

BlutdrucksenkendesMittel

Nein 0J 2

130-139 3140-149 4150-159 5160 6


166 170 14171-175 15176-180 16181-185 17186-190 18191-195 19196 -200 20>200 21

Triglyzeride (mg/dl)

<100 0100-149 2150-199 3200 4

Diabetes

Nein 0Ja 4

120 3

Familiäre Belastung

Nein 0Ja 5

Ja 2


43

PROCAM Score (2004)

Anzahlder Punkte

89-11

12-1314 16

Anzahlder Punkte

34353637

Anzahlder Punkte

55565758

myocardial infarctionrisikoin 10 Jahren (%)

0.10.20 3


2.93.23.5


18.319.021 314-16

171819 20212223242526

373839404142434445464748

585960616263646566676869

0.30.40.50.60.7 0.80.91.0 1.11.21.31 4

3.53.84.14.54.7 5.25.66.0 6.97.38.29 1

21.323.625.427.830.132.034.036.038.041.043.045 0


27 282930313233

48495051525354

6970717273

1.41.51.71.92.12.22.42.6

9.110.110.912.012.813.414.316.7

45.048.051.054.057.060



Source: Riesen et al, Switzerlanderische Aerztezeitung 2005;86:Nr 22

44

CVD Risk Score: Framingham PROCAM SCOREPopulation General population* Male labour force General populationsAge range at recruitment 30-74 35-65 24-80Sample size 10,156 (+1,176)* 5,389 205,178Region USA Germany EuropeTime of recruitment 1948-1979 (Gen I&II) 1979-1985 1967-1988Time of follow-up Ongoing Ongoing Partially ongoing

Risk factorsAge + + +Sex + (+) +Blood pressure + + +LDL-Cholesterol (inl. Friedewald) + + +HDL-Cholesterol + + +Triglycerides - + -Tobacco + + +Diabetes + + -Family history of MI - + -

CVD endpoint Morbidity and Mortality Morbidity and Mortality Mortality


p y y y y yRisk period 10 years 10 years 10 years

Number of eventsCHD 623§ 325& 5,652Total CVD 432 7,934$

*without and with history of CVD§Myocardial infarction, coronary insufficiency, angina pectoris, and sudden and nonsudden coronary death (mostly hospitalized events)&Sudden cardiac death or fatal or nonfatal myocardial infarction (based on ECG, enzyme changes)$Fatal events according to ICD-9 (401-141; 426-443, except for 426.7, 429.0, 430.0, 432.1, 437.3, 437.4, 437.5; 798.1, 798.2)

MetabolicSyndrome:

WHO NCEP ATP III EGIR IDF

Impaired glucose regulation, diabetes or insulin resistance and ≥ any two of the other four criteria

Three or more of the following:

Insulin resistance (upper quartile of fasting insulin values) and any two of the following

Central obesity and ≥ any two of the other four criteria

Central obesity WHR > 90 cm (M) > 85 cm (F) or BMI >30 kg/m2

Waist circumference > 102 cm (M) or > 88 cm (F)

Waist circumference ≥ 94cm (M), ≥ 80cm (F)

Waist circumference ≥ 94 cm (M) or ≥ 80 cm (F)

Triglycerides ≥ 1.7 mmol/l (150 mg/dl) ≥ 1.7 mmol/l (150 mg/dl) ≥ 2.0 mmol/l or … ≥ 1.7 mmol/l (150 mg/dl)g y ( g )and/or HDL < 0.9 mmol/l (35 mg/dl) M /< 1.0 mmol/l (39 mg/dl) F

( g ) ( g )

High density lipoprotein (HDL) cholesterol

< 1.03 (40 mg/dl) (M) or < 1.29 (50 mg/dl) (F)

… < 1.00 mmol/l < 1.03 mmol/l (40 mg/dl) (M) or < 1.29 mmol/l (50 mg/dl) (F)

Blood pressure ≥ 140/90 mmHg ≥ 130/85 mmHg ≥ 140/90 mmHg ≥ 130/85 mmHg or Treatment

Fasting blood glucose

≥ 6.1 mmol/l (110 mg/dl) or known diabetes

≥ 6.1 mmol/l (110 mg/dl) 6.1 (110 mg/dl) - 7.0 mmol/l (126 mg/dl)

≥ 5.6 mmol/l (100 mg/dl) or known diabetes


Two hour blood glucose

≥ 7.8 mmol/l (140 mg/dl) 7.8 mmol/l (140 mg/dl) - 11.1 mmol/l (200 mg/dl)

Insulin Insulin resistance (upper quartile of HOMA-index)

Insulin resistance (upper quartile of HOMA-index)

Microalbuminuria Microalbuminuria ≥ 20 µg/min or albumin : creatinine ratio (ACR) ≥ 30 mg/g

In bold: index factor; M: male; F: female; WHR: Waist-to-Hip-Ratio

45

„Non-traditional“ blood lipids

• Apolipoprotein AI (from HDL-C) & B (from LDL-C)

• Lipoprotein (a) (modifyed LDL-C)

• LDL-C density / size


LDL C density / size


46

Incidence of Major Coronary EventsAccording to Lp(a)

7280

Observed events per 1,000 in 8 years

19

33

5158

0

20

40

60


0

0.02 <0.10 <0.20 <0.30 0.30

prevalence: 18% 53% 11% 8% 10%

Lipoprotein (a) g/L 33 coronary events in 2,861 men, aged 40-65 years,


LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)

and Drug Therapy in Different Risk Categories

LDL Level at Which

Risk CategoryLDL Goal(mg/dL)

LDL Level at Which to Initiate

Therapeutic Lifestyle Changes

(TLC) (mg/dL)

LDL Level at Which to Consider

Drug Therapy (mg/dL)

CHD or CHD Risk Equivalents

(10-year risk >20%)<100 100

130 (100–129: drug

optional)

2+ Risk Factors

10-year risk 10–20%: 130


2+ Risk Factors (10-year risk 20%)

<130 13010-year risk <10%:

160

0–1 Risk Factor <160 160

190 (160–189: LDL-lowering drug

optional)


47

ATP III G id liATP III Guidelines

Therapeutic LifestyleChanges (TLC)


Changes (TLC)


Visit 2 Visit 3E l t LDL

A Model of Steps in Therapeutic Lifestyle Changes (TLC)

• Reinforce reductionin saturated fat andcholesterol • Initiate Tx for

6 wks 6 wks Q 4-6 mo

• Emphasizereduction insaturated fat &cholesterol

E

Visit I

Begin LifestyleTherapies

Evaluate LDLresponse

If LDL goal notachieved, intensifyLDL-Lowering Tx

Evaluate LDLresponse

If LDL goal notachieved, consideradding drug Tx

MonitorAdherenceto TLC

Visit N


• Consider addingplant stanols/sterols

• Increase fiber intake

• Consider referral toa dietitian

MetabolicSyndrome

• Intensify weightmanagement &physical activity

• Consider referral to a dietitian

• Encouragemoderate physicalactivity

• Consider referral toa dietitian


48

Steps in Therapeutic Lifestyle Changes (TLC)

First Visit

• Begin Therapeutic Lifestyle Changes

• Emphasize reduction in saturated fats and cholesterol

• Initiate moderate physical activity

• Consider referral to a dietitian (medical nutrition therapy)

• Return visit in about 6 weeks



Second Visit

• Evaluate LDL response

• Intensify LDL-lowering therapy (if goal not achieved)

– Reinforce reduction in saturated fat and cholesterol

– Consider plant stanols/sterols

– Increase viscous (soluble) fiber

– Consider referral for medical nutrition therapy





49


Third Visit

• Evaluate LDL response

• Continue lifestyle therapy (if LDL goal is achieved)

• Consider LDL-lowering drug (if LDL goal not achieved)

• Initiate management of metabolic syndrome (if necessary)

– Intensify weight management and physical activity

• Consider referral to a dietitian


Consider referral to a dietitian


Therapeutic Lifestyle Changes in LDL-Lowering Therapy

Major Features

• TLC Diet– Reduced intake of cholesterol-raising nutrients (same as

previous Step II Diet)• Saturated fats <7% of total calories• Dietary cholesterol <200 mg per day

– LDL-lowering therapeutic options• Plant stanols/sterols (2 g per day)


( g p y)• Viscous (soluble) fiber (10–25 g per day)

• Weight reduction • Increased physical activity


50

AHA 2006 Diet and Lifestyle Goals for Cardiovascular Disease Risk Reduction

• Consume an overall healthy diet.

• Aim for a healthy body weight.

• Aim for recommended levels of LDL, HDL, and TG.

• Aim for a normal blood pressure.

• Aim for a normal blood glucose level.


Source: Circulation. 2006;114:82-96

• Be physically active.

• Avoid use of and exposure to tobacco products.

AHA 2006 Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction

• Balance calorie intake and physical activity to achieve or maintain a healthy body weightor maintain a healthy body weight.

• Consume a diet rich in vegetables and fruits.

• Choose whole-grain, high-fiber foods.

• Consume fish, especially oily fish, at least twice a week.



51

AHA 2006 Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction

• Limit your intake of saturated fat to <7% of energy, trans fat to <1% of energy and cholesterol to <300 mg per day byfat to <1% of energy, and cholesterol to <300 mg per day by

— choosing lean meats and vegetable alternatives;

— selecting fat-free (skim), 1%-fat, and low-fat dairy products; and

— minimizing intake of partially hydrogenated fats.

• Minimize your intake of beverages & foods with sugar.


• Choose and prepare foods with little or no salt.

• If you consume alcohol, do so in moderation.


Einfluss auf Herz-Kreislauf-Risiko*

Evidenz vermindert RisikoKeinen

Einflusserhöht Risiko

Über-zeugend

Körperliche AktivitätFisch und Fischöle (EPA, DHA**)Früchte und GemüseKalium

Vitamin E-Supplemente (bei Gesunden)

Körperliche InaktivitätGesättigte Fettsäuren TransfettsäurenHoher Salzkonsum BMI ≥ 30 (Adipositas v aKalium

Niedriger bis moderater Alkoholkonsum (für CHD)

BMI ≥ 30 (Adipositas, v.a. zentrale)Exzessiver Alkoholkonsum

Wahr-scheinlich

α-LinolensäureÖlsäureNahrungsfasernNüssePflanzensterine

StearinsäureFolsäureKaffee

NahrungscholesterinHochdosierte Vitamisupplemente (B-Vit., Beta-Carotin, Vit. E)

möglich Schwarze Schokolade BMI 25-30 Ü

Laurinsäure


Sek. Pflanzenstoffe (Flavonoide, Polyphenole)Sojaprodukte

(Übergewicht) Frühgeburtlichkeit, niedriges (SGA) oder sehr hohes Geburtsgewicht

Unzu-reichend

Kalzium, MagnesiumSelen

Vitamin C Kohlenhydrate (Fruktose)Eisen

*Modifizierte Version der WHO (2002)**EPA: Eikosapentaensäure, DHA: Docosahexaensäure

52

Entscheidende Faktoren für Herz-Kreislauf-Erkrankungen in der Switzerland*

Risikofaktoren Protektive Faktoren

Steigende / stagnierende Adipositas-Prevelance

Zu viel

Leistungsfähiges Gesundheitssystem

Abnehmende RaucherPrevelance

*aufgrund der vorliegenden Evidenzen

Zu viel… Energiezufuhr im Verhältnis zum

Energieverbrauch Einfachzucker n-6 (wenn Ungleichgewicht zwischen n-6

und n-3) Fettsäuren (FS), Gesättigte FS, Trans-FS

Salz Exzessiver Alkoholkonsum Rauchen

Mehr Schutz vor Passivrauch

Eindämmung der Feinstaub-Belastung

Genügende Zufuhr an Nahrungsfasern

Moderater Alkoholkonsum

Abnehmender Konsum von tierischen


Nicht genug… Früchte und Gemüse Fisch komplexe Kohlenhydrate körperliche Aktivität

Fetten zugunsten pflanzlicher Fette

Source: Paccaud & Faeh 5. Switzerland. Ernährungsbericht, s493-512

Ernährungsempfehlungen nach D-A-CH*

NährstoffMenge im Verhältnis zur

empfohlenen Tageszufuhr Menge pro Kilo Körpergewicht

Gesamte Energiezufuhr 100% 30 - 50 kcal (126 - 209 kJ)**

Kohlenhydrate 50 à 60% 4 g

Eiweiss 10 à 20% 0.8 g

Fett (totale) 30% 1 g

Gesättigte Fettsäuren (FS) 1/4 - 1/3 der Gesamtfettzufuhr

Einfach ungesättigte FS 1/3 - 1/2 der Gesamtfettzufuhr

Mehrfach ungesättigte FS 1/4 - 1/3 der Gesamtfettzufuhr

6 2 5%


n-6 2.5%

n-3 0.5%

Cholesterol < 300 mg/Tag

Nahrungsfaseren > 30 g/Tag

* ungefähre Werte für erwachsene Personen

** abhängig von Alter, Geschlecht und körperlicher Aktivität

Source: Paccaud & Faeh 5. Switzerland. Ernährungsbericht, s493-512

53

Nutzen verschiedener PräventionsmassnahmenRisikofaktor Intervention Reduktion

CVD-Ereignisse

Rauchen Rauchstopp 30-50%

Hypertonie Antihypertensiva 30-40%

Dyslipidämie Cholesterinsenkung 20-40%

Adipositas Lebensstiländerung 20-30%

Typ-2-Diabetes Statinekörperliche Aktivität

40%30-50%


Bewegungsmangel körperliche Aktivität 20-50%

Plättchenaggregation/Hochrisikopatienten

20%

Source: Battegay et al, Atheroskleroseprävention, 2007, s57

www.cdc.gov/HeartDisease

www.who.int/cardiovascular_diseases

http://lysander sourceoecd orghttp://lysander.sourceoecd.org

www.nlm.nih.gov

www.swissheart.ch

www.agla.ch

b h


www.obsan.ch

www.assmann-stiftung.de

www.statistik.admin.ch

54

www.davidfaeh.ch/lehre


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