1. Cardiovascular Disease from the Canadian and International Perspectives Dr. Sonia Anand MD, PhD Professor of Medicine McMaster University Canadian Heart Health Strategic –Action Plan

2. Overview Global Burden of CVD Canadian Burden of CVD Ethnic Variations in Risk factors Association between Risk factors and CVD Strategies for Prevention Call for Action

3. CHANGE IN THE RANK ORDER OF DISEASE BURDEN FOR 10 LEADING CAUSES, WORLD, 1990-2020 (DALYS) 1. Lower resp infection 2. Diarrh diseases 3. Perinatal 4, Major depression 5. Coronary heart dis 6. Stroke 7. TB 8. Measles 9. Traffic accidents 10. Cong anomalies 1 Coronary heart disease 2. Major depression 3. Traffic accidents 4. Stroke 5. COPD 6. Lower resp infections 7. TB 8. War 9. Diarrhoeal disease 10. HIV 19902020

4. Reddy K. N Engl J Med 2004;350:2438-2440 Worldwide Deaths from Cardiovascular Causes Millions of Deaths from Cardiovascular Disease

5. Numbers with DM (Diagnosed) Diabetes Care 2004:1047

6. Age-standardized mortality rates of CVD and Cancer in Canada Per 100,000 Statistics Canada CVD= IHD, CBVD, DM, ATH

8. Risk FactorProportion of the Population Aged 20-59 Years (%) Tobacco Smoking (Daily)25.7 Physical Inactivity55.5 Overweight (BMI > 25.0)47.5 Less than Recommended Consumption of Fruits and Vegetables 64.7 High Blood Pressure8.3 Diabetes*2.7 Source: Statistics Canada, Canadian Community Health Survey The Growing Burden of Heart Disease and Stroke in Canada 2003 Canada’s Modifiable Risk Factors

9. Comparing Ethnic Groups

10. Mortality for CHD and Cancer  Age 35 – 74 (1979-1993) Sheth et al, CMAJ 1999

11. 74% 24% Immigrants Aboriginal 922,000 Chinese 723,000 South Asians 1,100,000 + Aboriginal people

12. SHARE: Study of Health Assessment and Risk in Ethnic Groups Random Sample - Europeans, South Asians, Chinese, Aboriginal Environmental Factors Lifestyle Nutrition Psychosocial Cultural Genetic Factors Risk Markers Lipids Coagulation Glucose BP Antioxidants Homocysteine Subclinical Disease Carotid Ankle Arm BP LVH Micro Alb. Clinical Events CAD Stroke PVD Anand S et al Can J Cardiol 1998

13. Percent Distribution By Province of Registered Indian Population in Canada

14. Overweight and Abdominal Fat Anand et al SHARE Lancet 2000/1 BMI ≥30; WHR > 0.85 (female)/1.0 (male) % Age and sex Adjusted

15. ↑ Glucose: Dysglycemia 11 Anand et al SHARE

16. Razak et al Circ 2005 BMI=21 BMI = 30 Relationship of Glucose Factor to BMI in Non-white ethnic groups

17. Age and Sex Adjusted CVD Prevalence comparing Ethnic Groups in Canada Anand et al SHARE

18. SHARE- Nutrition South Asians ChineseEuroAP N 17316718592 Age 46.345.847.751.6 Calories/Day 1911189820722242* % Vegetarian 18.8*2.10.61.2 Total Fat g/day 59.170.3*61.869.8 Saturated Fat g/day 19.617.3*21.625.7 Carbohydrates g/day 298.8*240.7269.5256.7 Sugar g/day 11.2*6.98.96.7 Protein g/day 70.1*100.5*78.082.1 Anand et al SHARE

19. SHARE- Fat Intake South Asians ChineseEuro Fried Foods (# serv./week) 4.83.95.0 Total Fat g/day59.170.3*61.8 Saturated Fat g/day19.617.3*21.6 Trans Fats (g)0.340.270.56*

20. SHARE- Fish South Asian ChineseEuro Fish (# serv./week)1.16.3*1.6 Omega-3 FA0.130.760.04 Omega-6 FA0.370.420.31

21. Anand, S. S et al. Int. J. Epidemiol. 2006 35:1239-1245; doi:10.1093/ije/dyl163 Aboriginal and South Asian ♂ Aboriginal and South Asian ♀ Chinese ♂/ ♀ Risk of CVD and Social Disadvantage

22. Changes in Risk Factors with Migration

23. EVOLUTION OF RISK FACTORS IN URBAN MIGRANTS  Calories  Activity Cultural Stressors Diabetes Hypertension Dyslipidemia  CVD

24. INTERHEART: Design Cases: First Acute Myocardial Infarction (n=15,152) Controls: Matched to cases by age (+/-5 yr and sex) at each site (n=14,820) Data collected from 262 sites in 52 countries Coordinated by the Population Health Research Institute, McMaster University, Canada Ounpuu S et al Am Heart J 2001

25. Risk Factor Frequency Varies Are the same risk factors important in all ethnic groups, age groups, and women and men?

26. INTERHEART: Design Cases: First Acute Myocardial Infarction (n=15,152) Controls: Matched to cases by age (+/-5 yr and sex) at each site (n=14,820) Data collected from 262 sites in 52 countries Coordinated by the Population Health Research Institute, McMaster University, Canada Ounpuu S et al Am Heart J 2001

27. INTERHEART: > 27,000 Cases and Controls

28. INTERHEART Global Case-Control Study: Nine Modifiable Risk Factors Smoking Elevated Lipids: ↑ ApoB/Apo A ratio Diabetes Hypertension Abdominal Obesity: ↑ Waist to Hip Ratio Physical Activity: > 4 hrs/week Alcohol: ≥ 3 drinks/week Fruit and Vegetable Consumption: Daily Psychosocial Stress: Work/home stress, depression, financial stress, locus of control >27,000 subjects 52 Countries 6000 women > 12,000 > age 60 yrs

29. Risk of MI associated with Risk Factors in the Overall Population Risk factor% Cont % CasesOR (99% CI) adj for all PAR (99% CI) ApoB/ApoA-1 (5 v 1) 20.033.53.25 (2.81, 3.76) 49.2 (43.8, 54.5) Curr smoking 26.845.22.87 (2.58, 3.19) 35.7 (32.5,39.1) Abd Obesity (3 v 1) 33.346.31.62 (1.45, 1.80) 20.1 (15.3, 26.0) Hypertension 21.939.01.91 (1.74, 2.10) 17.9 (15.7, 20.4) Diabetes 7.518.42.37 (2.07, 2.71) 9.9 (8.5, 11.5) Psychosocial --2.67 (2.21, 3.22) 32.5 (25.1, 40.8) Veg & fruits daily 42.435.80.70 (0.62, 0.79) 13.7 (9.9, 18.6) Exercise 19.314.30.86 (0.76, 0.97) 12.2 (5.5, 25.1) Alcohol Intake 24.524.00.91 (0.82, 1.02) 6.7 (2.0, 20.2) All combined (extremes) 333.7 (230.2, 483.9) 90.4 (88.1, 92.4)

30. Risk Factors for Acute MI in the Overall Population Risk factor% Cont % CasesPAR (99% CI) ApoB/ApoA-1(5 v 1)20.033.549.2 (43.8, 54.5) Current smoking26.845.235.7,(32.5,39.1) Psychosocial--32.5 (25.1, 40.8) Abd Obesity (3 v 1)33.346.320.1 (15.3, 26.0) Hypertension21.939.017.9 (15.7, 20.4) No Veg & fruits42.435.813.7 (9.9, 18.6) Low Physical Activity19.314.312.2 (5.5, 25.1) Diabetes7.518.59.9 (8.5, 11.5) No Alcohol24.524.06.7 (2.0, 20.2) Combined-- 90.4 (88.1, 92.4) Over 90% of AMI are predicted by these nine risk factors Lancet 2004

31. INTERHEART: Apolipoprotein B/A-1 and MI Deciles: 1 2 3 4 5 6 7 8 9 10 Cont 1210 1206 1208 1207 1210 1209 1207 1208 1208 1209 Cases 435 496 610 720 790 893 1063 1196 1366 1757 Median 0.43 0.53 0.60 0.66 0.72 0.78 0.85 0.93 1.04 1.28 1 2 4 8 OR (99% CI)

32. INTERHEART: Smoking and MI 1 2 4 8 16 Cont 7489 727 1031 446 1058 96 230 168 56 Cases 4223 469 1021 623 1832 254 538 459 218 OR 1 1.38 2.10 2.99 3.83 5.80 5.26 6.34 9.16 Never 1-5 6-10 11-15 16-20 21-25 26-30 31-40 41+ OR (99% CI)

34. Independent risk of MI associated with 2 markers of obesity BMI - adjusted for age, sex, smoking, region …+ WHR WHR adjusted for age, sex, smoking, region … + BMI

35. INTERHEART DIETARY ANALYSIS Methods – 6,530 cases and 10,792 controls –19 items food groups questionnaire Dietary Patterns: –Prudent diet: raw and cooked vegetables, legumes and fruits –Oriental diet: tofu, soy sauce and green leafy vegetables –Western diet: dairy, fried foods and meats (high in saturated fats)

36. Dietary Intake Varies by Ethnicity Dietary Patterns: –Prudent diet: raw and cooked vegetables, legumes and fruits –Oriental diet: tofu, soy sauce and green leafy vegetables –Western diet: dairy, fried foods and meats (high in saturated fats) Iqbal et al 2006

37. Adjustment factors Age, sex, region, BMI, WHR, physical activity, alcohol intake, smoking, apoB/apoA1, psycho-social factors, and education Iqbal R et al 2006 INTERHEART: Relative Risk of MI by Dietary Type ↓ 24% ↑ 29%

38. Risk factors the same, Frequency Varies Risk factors for MI are the same for all ethnic groups, young and old, and women and men.

39. Association between Risk factors and CHD is similar btwn ethnic groups CHD Dysglycemia Smoking Dyslipidemia Risk Factors Disease Determinants Adiposity Psychosocial Stress Blood Pressure Physical Inactivity ETOH Diet Quality Physical activity Stress Air Pollution Consistent btwn ethnic groups Genetic Factors Environment

40. Prevention and Treatment of Risk Factors/CVD

41. Frequency of INTERHEART RISK Factors in Cases and Controls Number of Subjects Number of Interheart Risk Factors

42. Risk Factors are Ubiquitous in the Population – We are all at Risk 80% of Canadians have 1 Risk Factor 30% of Canadians have 2 Risk Factors 11% have 3 or more Risk Factors Source: Statistics Canada, Canadian Community Health Survey

43. INTERHEART: Decreased Risk of AMI with Avoidance of Smoking; Daily Fruits/Veg, Reg Phys Activity & Alcohol 0.35 0.70 0.86 0.91 0.24 0.21 0.19 0.125 0.25 0.5 1.0 no smkFrt/VegExerAlcNosmk+fvg+Exer+Alc OR (99% CI) All the “right” things reduce odds of AMI by 80%

44. RCT Evidence that Altering Risk Factors Lowers CHD Risk FactorRCT EvidenceStrong Alternative Evidence Abnormal Lipids Yes Smoking No Yes (36 % RR) ↑Blood Pressure Yes DiabetesAccumulating Yes Abdominal Obesity Some Yes Physical Activity Yes Fruits and vegetable Yes Iestra et al Circulation 2005

45. Can we prevent 90% of MI in young and middle age NOW? NO Can we prevent >90% of MI in young and middle age in the foreseeable future? YES How can we prevent the majority of premature CHD?

47. Prevention of Cardiovascular Disease - Individual Approach GOAL Type of Strategy Examples Individuals with Risk Factors for CVD Interventions with a Preventive Focus Identifying & treating ↑ Cholesterol or Hypertension Smoking cessation Individuals with CVD Interventions with a Clinical Focus Lipid Lowering Aspirin Beta blockers ACE-inhibitors Appropriate revascularization

48. Risk Factor Detection and Control Behavior Change Policy and Environmental Change Emergency Care or Acute Case Management Rehabilitation or Long-term Case Management End-of-Life Care PREVENTION, 5% of Resources High- Risk Treatment Intervention Approaches TREATMENT, 95% of Resources

49. Greatest Gains in Preventing CVD: Population Approach 10 Year Cardiovascular Disease Risk % of Population High Risk Present Distribution Optimal Distribution

50. Swimming Upstream Fast Food Energy Saving Devices Tobacco Advertising Simple Lifestyle Intervention

51. A Societal Pathophysiologic Pathway for COR HT DIS RURAL LIFESTYLE Proximal Determinants of Behaviour urban structure & mechanization Food & Tobacco policy Cultural attitudes Social/Education Global influences URBAN LIFESTYLE Consumption of energy rich food Sedentariness (in usual daily activities) Psychosocial factors Obesity and other risk factors Modifying influences: Healthcare Genes Knowledge & Attitudes Clinical Events ++ - Yusuf et al. Circ 2001

52. Prevention of Cardiovascular Disease: Population Approach GOAL Type of Strategy Examples Determinants of Risk Behaviours in a Population Interventions with a Socio-Economic & Political Focus Taxing Tobacco Subsidizing healthy foods Promote Physical Activity by improving Built Environment

53. Intervening on the causes of CV risk factors

54. Change in commuting patterns in the US (from 1980 to 2000) Commuting in America III - A Pisarski, American Highway Users Alliance: Census Bureau % % % % % % % %

55. Leading risk factors for disease burden in 2000 by development category (% total DALYS) Developed CountriesDeveloping Countries Tobacco – 12.2%Underweight – 14.9% Blood pressure – 10.9%Unsafe Sex – 10.2 Alcohol -9.2%Unsafe Water, Hygiene – 5.5% Cholesterol – 7.6%Indoor Smoke – 3.6% Overweight – 7.4%Zinc Deficiency – 3.2% Low Fruit and Vegetable Intake – 3.9% Iron Deficiency – 3.1% Physical Inactivity – 3.3%Vitamin A Deficiency – 3.0% Illicit Drugs – 1.8%Blood Pressure – 2.5% Unsafe Sex – 0.8%Tobacco – 2.0% Iron Deficiency - 0.7%Cholesterol – 1.9%

56. Finland’s Decline in CHD Mortality over 20 years Age BMJ. 1994 Jul 2;309(6946):23-7 National Strategy ↓ Dairy Product, ↑ Vegetables, ↓ Salt, ↓Animal fats

57. Decline in Risk Factors in men in Finland BMJ. 1994 Jul 2;309(6946):23-7 Men aged 35 – 63

58. How can we prevent 90% of MI by 2030? 1.Some “causal” risk factors that are modifiable [such as HDL (ApoA), abdominal obesity, hip size, diabetes] need to be changed and demonstrated to reduce CHD 2. LARGE reductions in multiple risk factors are needed 3. Practically ALL adults in Urbanized Societies have abnormalities of at least one risk factor. Treat all? (e.g. Polypill) Prevent the development of risk factors (Societal interventions - i.e. tobacco policy, community re-design, food supply)

59. Canadian Landscape Need for Public Health Programs to unite against CV Risk Factors (which overlap with Cancer RF’s) Partnerships at multiple policy levels (National, Provincial, Regional) Need for Target setting and Evaluation of Progress Robinson et al 2007