The power of lifestyle interventions to prevent cardiovascular diseases. Tuomilehto J. Conference on Cardiovascular Diseases (Madrid: Ministry of Health and Social Policy; 2010).

1. The power of lifestyle interventions
to prevent cardiovascular disease
and type 2 diabetes.
Prof. Jaakko Tuomilehto
Department of Public Health,
University of Helsinki

2. DEVELOPED COUNTRIES – year 2000
Deaths attributable to 15 leading causes
Cardiovascular diseases
Malignant neoplasms
Injuries
Respiratory diseases
Digestive diseases
Respiratory infections
Neuropsychiatric disorders
Diabetes mellitus 98% of all deaths
Diseases of the genitourinary system attributable to
Perinatal conditions 15 leading causes
Tuberculosis
Nutritional/endocrine disorders
Other neoplasms
Congenital abnormalities
Musculoskeletal diseases
0 1000 2000 3000 4000 5000 6000 7000
Source: WHR 2002
Number of deaths (000s)

3. DEVELOPED COUNTRIES – year 2000
Deaths attributable to selected leading risk factors
Blood pressure
Tobacco
Cholesterol
High Body Mass Index
Low fruit and vegetable intake
Physical inactivity
Alcohol
Urban air pollution
Lead exposure
Occupational carcinogens
Illicit drugs
Unsafe sex
Occupational particulates
Occupational risk factors for injury
0 500 1000 1500 2000 2500 3000
Number of deaths (000s)

4. WHO MONICA Project
Monitored
10 year CHD trends from mid 1980s – mid 1990s
across 37 populations in 21 countries
166,000 events registered during 371 population­years
0
Fall in CHD mortality rates ­27%
-2 0 0 0 0
Event rates ­21%
-4 0 0 0 0
(incidence ≅ risk factors)
-6 0 0 0 0
Case fatality –6%
≅
(≅ treatments)
-8 0 0 0 0
Tunstall-Pedoe et al. Contribution of trends in survival & coronary­
event rates to changes in CHD mortality Lancet 1999 353 1547

5. IMPACT Model: Main Components
Cholesterol BMI & Diabetes
RISK Blood Pressure Activity
Smoking Physical
F FACTORS Blood Pressure
Age & Sex
Patient
Groups AMI Angina Heart Failure 2' Prevention
CABG/PTCA
TREATMENTS Medical Therapy
Medical surgery
OUTCOMES Death Survival
Unal, Critchley & Capewell
Unal,
Circulation 2004 109(9) 1101­7
1101­

6. Mortality per
100 000 700
start of the North Karelia Project
population
600
extension of the Project nationally
Age-adjusted CHD
500
mortality rate in
North Karelia and
North Karelia
400
the whole of
Finland.
300
Men 35-64 years - 82 %
200
All Finland
during 1969 - 2002.
- 75%
100
69 72 75 78 81 84 87 90 93 96 99 2002
Year
29

7. Diastolic Blood Pressure
mmHg
Women 30-59 Years
95
90
North Karelia
Kuopio
Turku/Loimaa
85
Helsinki/Vantaa
Oulu Province
80
Lapland
75
1972 1977 1982 1987 1992 1997 2002

8. Serum cholesterol in Finnish men aged 25-64
years
mmol/l
7
6,5
North Karelia
Kuopio
Turku/Loimaa
6
Helsinki/Vantaa
Oulu
5,5
Lapland
5
1982 1987 1992 1997 2002 2007

9. CHANGE IN SERUM CHOLESTEROL IN
FINLAND 1982-2002*
MEN
Miehet
0,1
PUFA
0 Diet cholesterol
Dietaarinen
kolesteroli
-0,1
SFA
-0,2
mmol/l
Keys
-0,3
SFA+trans
-0,4
Keys (trans) **
-0,5 Mitattu S-Kol
Measured serum
-0,6 cholesterol
1982 1992 2002

10. CHANGE IN SERUM CHOLESTEROL IN
FINLAND 1982-2002*
WOMEN
Naiset
0,1
PUFA
0 Diet cholesterol
Dietaarinen
kolesteroli
-0,1
SFA
mmol/l
-0,2
Keys
-0,3
SFA+trans
-0,4
Keys (trans) **
-0,5
Mitattu S-Kol
Measured serum
-0,6 cholesterol
1982 1992 2002
*

11. Use of butter on bread
%
(men 30-59)
100
North Karelia
90
Kuopio
80
Turku/Loimaa
70
Helsinki/Vantaa
Oulu
60
Lapland
50
40
30
20
10
0
1972 1977 1982 1987 1992 1997 2002

12. Use of vegetable oil
(men 30-59)
70
North Karelia
60
Kuopio
Turku/Loimaa
50
Helsinki/Vantaa
Oulu
40
Lapland
30
20
10
0
1972 1977 1982 1987 1992 1997 2002

13. 24-h sodium excretion as NaCl
20
Men, North Karelia
18
Men, Kuopio area
Men, Southwestern Finland
Men, Helsinki area
16
Women, North Karelia
Women, Kuopio area
14
NaCl g
Women, Southwestern Finland
Women, Helsinki area
12
10
8
6
1979 1982 1987 2002
YEAR
Laatikainen et al. Eur J Clin Nutr 2006

14. Comparing the observed male mortality rates from CHD in N.E.
Finland with those predicted from changes in the risk factors.
0
Smoking
-10
Blood
pressure
-20
Percent decline
Cholesterol
-30
-40
All three
risks
-50
Observed
mortality
-60
-70
1975 1980 1985 1990
Vartiainen et al. 1994.

15. DPS: The Finnish Diabetes Prevention Study
The main aim:
To determine whether lifestyle intervention of overweight,
middle-aged subjects with impaired glucose tolerance
(IGT) will prevent or delay the development of type 2
diabetes
Study subjects:
• 522 subjects with IGT in two oral glucose tolerance tests
• Age 40–65 years
• BMI > 25 kg/m2
• Randomization to standard care control group or
intensive lifestyle intervention group
N Engl J Med 2001; 344:1343

16. DPS - INTERVENTION GOALS
• Weight reduction: > 5% (BMI < 25 kg/m2)
• Total fat intake: < 30 E%
• Saturated fat intake: < 10 E%
• Fiber intake: > 15 g/1000 kcal
• Aerobic and muscle
strengthening exercise: > 30 min/day

17. Reduction of the incidence of diabetes during the
lifestyle intervention - DPS
1.0
0.9
0.8
0.7
0.6
Risk reduction: 58%
0.5
Intervention 0 1 2 3 4 5 6
group
Control group Year

18. DPS: Diabetes incidence
by the randomization group
during the total extended follow-up period
50
Log-rank test: p=0.0001
Cumulative incidence of T2D, %
Control
Hazard ratio=0.57 (95% CI 0.43-0.76)
40
30
20
Intervention
10
Intervention ceased
0
0 1 2 3 4 5 6 7 8
Follow-up time, years
Lindström et. al. Lancet 2006;368:1673-79

19. Changes in clinical and metabolic
parameters1
% 8
p<0.001
6
p=0.001
4
2 p<0.001 p<0.001
p<0.001 p<0.001 p=0.014 p=0.006
0
p=0.002
-2
-4
-6
-8
-10
-12
Weight Waist fPG 2-h PG fINS TG HDL SYST DIAS
1frombaseline to year 1
Intervention Control subjects with the MetS

20. Proportion of subjects becoming diabetic by success in
achieving the intervention targets at one-year
examination - DPS
50
% 45
40 Intervention Control
35
30
25
20
15
10
5
0
0 1 2 3 4 5
SUCCESS SCORE

21. 1-year lifestyle changes in the Intervention and
Control groups by FINDRISC
% 10,00
8,00
6,00
4,00
2,00
0,00
-2,00
-4,00
-6,00
Weight % Fat E% SaFat E% Fibre g / Exercise
1000kcal min/day
Intervention, low FINDRISC Intervention, high FINDRISC
Control, low FINDRISC Control, high FINDRISC
p for interaction (FINDRISC*group) ns for all

22. Change in total duration of leisure-time physical activity and
the reduction in incidence of diabetes – DPS:
the highest tertile (3.8 h/wk) versus the lowest tertile (-3.2 h/wk)
Model 1 Model 2 Model 3*
0
-10
Risk reduction (%)
-20
-30
-40
-50
-60
-70
-80
-90
* Adjusted for all baseline and follow-up variables

23. Change in duration of lifestyle leisure-time physical activity and
the reduction in reduction in incidence of diabetes -DPS:
the highest tertile (1.9 h/wk) versus the lowest tertile (-1.8 h/wk)
Model 1 Model 2 Model 3*
0
-10
Risk reduction (%)
-20
-30
-40
-50
-60
-70
-80
* Adjusted for all baseline and follow-up variables

26. Cumulative Incidence of Diabetes
100 HRR 0.57 (95% CI, 0.41 – 0.81)
93% 11.3% / yr
80
Percentage (%)
66% 80% 6.9% / year
60
40 43%
Control
Intervention
20
0
0 2 4 6 8 10 12 14 16 18 20
Years of follow up
*Age and cluster variable clinic adjusted

27. Cumulative Incidence of CVD Death
20 17%
1986-2006 HRR = 0.83 (95% CI 0.48 – 1.40) (0.9% / yr)
1993-2006 HRR = 0.73 (95% CI 0.42 – 1.26)
16
Percentage (%)
12 13%
Control (0.6 % / yr )
8 Intervention
4
0
0 2 4 6 8 10 12 14 16 18 20
Years of follow up

28. Hazard ratios for total and CVD mortality according
to leisure time activity among diabetic/IGT patients
- the Whitehall Study
Physical activity Total mortality CVD mortality
Low 1.65 (1.1-2.5) 3.60 (1.6-8.0)
Moderate 1.59 (1.1-2.4) 2.47 (1.1-5.4)
High 1.0 1.0
P for trend 0.03 0.02
Adjusted for age, BMI, systolic blood pressure, cholesterol, smoking and
disease at study entry.
Batty et al. Diabet Med 2002;19:580–8.

29. Physical activity and CVD mortality
among patients with type 2 diabetes –
The FINRISK Study

30. Multivariate-adjusted hazard ratios for total and
CVD mortality among diabetic patients
- occupational physical activity
Occupational Total mortality CVD mortality
physical activity
Low 1.00 1.00
Moderate 0.86 (0.74-1.00) 0.91 (0.75-1.10)
Active 0.60 (0.52-0.69) 0.60 (0.50-0.71)
P for trend <0.001 <0.001
Adjusted for age, sex, study year, BMI, systolic blood pressure, cholesterol,
smoking, and other two types of physical activity
Hu et al. Circulation 2004;110:666-73.

31. Multivariate-adjusted hazard ratios for total and
CVD mortality among diabetic patients
- commuting physical activity
Walking or Total mortality CVD mortality
cycling to work
0 1.00 1.00
1-29 min/d 0.82 (0.71-0.94) 0.81 (0.67-0.96)
>=30 min/d 0.75 (0.64-0.87) 0.74 (0.61-0.90)
P for trend <0.001 0.002
Adjusted for age, sex, study year, BMI, systolic blood pressure, cholesterol,
and smoking.
Hu et al. Circulation 2004;110:666-73.

32. Multivariate-adjusted hazard ratios for total and
CVD mortality among diabetic patients
- leisure-time physical activity
Leisure-time Total mortality CVD mortality
physical activity
Low 1.00 1.00
Moderate 0.82 (0.73-0.91) 0.83 (0.72-0.95)
High 0.71 (0.56-0.92) 0.67 (0.49-0.93)
P for trend <0.001 0.005
Adjusted for age, sex, study year, BMI, systolic blood pressure, cholesterol,
smoking, and other two types of physical activity
Hu et al. Circulation 2004;110:666-73.

38. Risk of AMI associated with Quartiles of Dietary Patterns
(95% CI) - INTERHEART
2.0 Age and for ageadj sex
sex and
Adjusted
Plus region, educ, BMI, physical activity,activity, smokingadj
Adjusted for age, sex, and region, education, BMI, physical smoking
Adjusted for all Interheart risk factors
All INTERHEART risk factors adj
Odds Ratio
1.0
0.5
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Oriental Dietary Pattern Western Dietary Pattern Prudent Dietary Pattern
Quartile Iqbal et al. Unpublished

39. Risk of AMI associated with Quartiles of Dietary Risk Score
(DRS) (95% CI) after adj for age, sex, region - INTERHEART
4.0
Overall
Overall
Women
Women
Men
Men
Odds Ratio
2.0
1.0
0.5
Q 1 Q2 Q3 Q4 Q1 Q 2 Q3 Q4 Q1 Q2 Q3 Q4
Overall Women Men
Score Quartile
Iqbal et al. Unpublished

40. OR (95% CI)
Population Attributable Risk and Odds Ratios for AMI
associated with Dietary Risk Score- INTERHEART
OR
PAR
Q4 vs Q1
0.30 1.92
Overalla
(0.26-0.35) (1.74-2.11)
0.28 1.90
Maleb
(0.23-0.33) (1.70-2.11)
0.39 2.55
Femaleb
(0.30-0.49) (2.00-3.23)
N. America, W.
0.30 2.12
Europe
(0.17-0.42) (1.61-2.78)
and Australiac
0.31 1.61
Central Europec
(0.18-0.44) (1.20-2.15)
0.28 1.81
Middle Eastc
(0.17-0.40) (1.41-2.33)
0.10 1.27
Africac
(-0.14-0.35) (0.82-1.97)
0.29 1.85
South Asiac
(0.18-0.40) (1.46-2.34)
0.18 2.02
Chinac
(0.07-0.29) (1.65-2.48)
0.58 4.27
Southeast Asiac
(0.45-0.71) (2.87-6.35)
0.15 1.80
S. Americac
(-0.03-0.32) (1.30-2.49)
a adjusted for age, sex and regions 0.5 1 2 4 8
b adjusted for age and regions
c Adjusted for age and sex
OR (95% CI) Iqbal et al.