Transcript Early and late management prevention of patients with

Overview and Rationale for the
PURE Study
Dubai, UAE
January 6, 7 2006
Life Enhancing: Average Life
Expectancy at Birth
Economist, Nov 2001
EPIDEMIOLOGIC TRANSITION OF
CARDIOVASCULAR DISEASES
Stages of
Development
% of total
deaths
from CVD
Predominant CVDs
Regions
1. Age of pestilence
& famine
5 to 10
Rheum. HD, infections,
nutritional cardiomyopathies
Sub-Saharan, Africa,
rural India, S.Amer
2. Age of receding
pandemics
10-35
As above + hyperten HD, and
hem strokes
3. Age of degen &
man-made dis
35-55
All strokes, IHD at young
ages, obesity & diabetes
Urban India, former
socialist econ,
aboriginals
4. Age of delayed
degenerative dis
< 50
Stroke and IHD at old age
W. Eur, N. America,
Austral, N-Zealand
5. Age of Health
Regression & Social
Upheaval
35-55
Re-emerg of rheumatic HD,
infections, IHD & hypertens
dis in the young
Russia
China
Contribution of NCD to the Global Mortality
and GBD in 1998, in LIC & MIC Countries
Disease
Category
Contrib of
NCD’s to
total global
mortality
(%)
LIC + MIC
Contrib of
LIC + MIC
Contrib to
NCD’s to
Contrib to
global NCD total burden NCD burden
mortality
of disease
of disease
(%)
(%)
(%)
77
43.0
85
Total NCD
58.8
CVD
30.9
78
10.3
86.3
Cancers
13.4
72
5.8
79
Diabetes
1.1
73
0.8
73
COPD
4.1
87.5
2.0
91.4
Schema of Relative CVD Rates in Different
Societies Based on Early vs Late Industrialization
India/China
5
Stage of EPI Transition
4
3
N.Am/W. Eur
2
1
0
1900
1950
2000
2050
REASONS FOR THE GLOBAL
INCREASE IN CVD
1.
2.
3.
Decrease in childhood and infectious diseases  more
middle age & older people
Increased tobacco used
Urbanization:
a)
b)
c)
d)
 phys activity during daily life (e.g. automation, cars, etc.)
 energy consumption
 fat consumption
 psychosocial stress
Increase in Wt/Obesity
Dyslipidemia, Dysglycemia,  BP
Percent of Population Living in
Urban Settings 1970-2025
Region
1970
1994
2025
World
36.6
44.8
61.1
Developed
Countries
Economies in
Transition
Developing
Countries
67.5
74.4
84.0
25.1
37.0
57.0
12.6
21.9
43.5
Risk of AMI associated with Risk Factors
in the Overall Population
Risk factor
ApoB/ApoA-1(5 v 1)
Curr smoking
Diabetes
Hypertension
Abd Obesity (3 v 1)
Psychosocial
Veg & fruits daily
Exercise
Alcohol
Combined
% Cont % Cases
20.0
33.5
26.8
45.2
7.5
18.5
21.9
39.0
33.3
46.3
42.4
35.8
19.3
14.3
24.5
24.0
-
PAR 1 (99% CI)
54.1 (49.6, 58.6)
36.4(33.9,39.0)
12.3 (11.2, 13.5)
23.4 (21.7, 25.1)
33.7 (30.2, 37.4)
28.8 (22.6, 35.8)
12.9 (10.0, 16.6)
25.5 (20.1, 31.8)
13.9 (9.3, 20.2)
PAR 2 (99% CI)
49.2 (43.8, 54.5)
35.7,(32.5,39.1)
9.9 (8.5, 11.5)
17.9 (15.7, 20.4)
20.1 (15.3, 26.0)
32.5 (25.1, 40.8)
13.7 (9.9, 18.6)
12.2 (5.5, 25.1)
6.7 (2.0, 20.2)
90.4 (88.1, 92.4) 90.4 (88.1, 92.4)
Population Attributable Risk by
Region and Overall
Region
W. Europe
E/C Europe
Middle East
Africa
S. Asia
China
S.E. Asia
Australia/NZ
S. America
N. America
Overall 1
Overall 2
Smoke %
28.9
30.2
44.8
38.0
37.5
35.8
36.2
44.7
38.5
26.3
36.2
35.7
LIFESTYLE FACTORS
Fr/vg %
Exer %
Alc %
12.9
38.8
18.9
10.2
11.3
12.9
8.1
4.0
-4.4
3.8
11.1
27.3
18.4
24.3
-5.3
17.8
21.1
5.3
11.2
31.4
27.9
10.7
23.8
18.5
6.7
27.2
-3.1
19.8
25.3
25.3
12.9
25.5
13.9
13.7
12.2
6.7
All LS
67.8
49.6
45.5
63.2
55.2
62.4
69.9
65.8
56.9
59.8
62.8
54.6
Population Attributable Risk by
Region and Overall
Region
HTN %
W. Europe
22.0
E/C Europe
24.5
Middle East
9.7
Africa
29.9
S. Asia
19.4
China
22.1
S.E. Asia
38.4
Australia/NZ 22.8
S. America
32.8
N. America
18.9
Overall 1
23.4
Overall 2
17.9
NON-LIFESTYLE RISK FACTORS
Diab % Abd Obes % All PS% Lipids % All 9 RF
14.9
63.6
38.9
44.6
94.0
9.1
28.0
4.9
35.0
72.5
15.5
26.7
41.6
70.5
95.0
17.1
58.3
40.0
74.1
97.4
12.1
37.0
15.9
58.7
89.4
10.0
5.5
35.6
43.8
89.9
21.0
58.0
26.7
67.7
93.7
7.2
61.6
28.9
43.4
89.5
12.8
45.4
35.6
47.6
89.4
7.9
59.6
51.4
50.5
98.7
12.4
33.7
28.8
53.8
90.4
9.9
20.1
32.5
49.2
90.4
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
-•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
++
URBAN LIFESTYLE
Yusuf et al. Circ 2001
What is a normal BMI?
Normal” derived from modern day Western countries
may not be appropriate .
“
• Median BMI of newborns :13(USA)
• Median BMI of 16 yr olds:16(USA)
• Median BMI of 20 yr olds:20(USA)
• Median BMI of adult males in the 1900:21(USA)
• Median BMI of rural B Lore :19.5(India)
• Median BMI in Anquing study: 19 (China)
So, why is a BMI of 25 considered to be normal?
INTERHEART: Apolipoprotein B/A1 and MI
8
OR (99% CI)
4
2
1
Deciles:
1
2
3
4
5
1210
1206
1208
1207
1210
Cases
435
496
610
720
Median
0.43
0.53
0.66
Cont
0.60
6
7
8
9
10
1209
1207
1208
1208
1209
790
893
1063
1196
1366
1757
0.72
0.78
0.85
0.93
1.04
1.28
Conceptual issues in examining regional
variations in disease
1. State of development of the country or region in
relation to the epidemiological transition.
2. Level of urbanization.
3. Variations in ethnicity (cultural and biological)
4. Socioeconomic status, lifestyle (local level
variations)
Four major transitions associated with
urbanization (1)
1. Mechanization, motorization, energy saving
devices
 changing economic structure, with increasing importance of nonagricultural sectors
 increasing investment in telecommunications, transportation and
electrical infrastructure
2. Declining physical activity


More sedentary modes of transportation
Changing work structure, increased mechanization leads to less
energy expenditure at work and home
Four major transitions associated with
urbanization (2)
3. Changing dietary patterns


Shift in food production, distribution, availability and costs
Higher energy, fat, animal protein, refined and processed food intakes,
lower intake of traditional grains, fruits, vegetables, greater variety
4. Changing stressors, quality of social support



Fragmentation of traditional family structure
Increased job stress
Absence of community support systems (social capacity)
Urban Versus Rural Environments:
Not dichotomous or unchanging
• Marked variations within urban and rural environments, but also
between urban and rural environments within a region
• Directions of differences in social, cultural and biologic differences
between urban and rural environments vary between HIC, MIC and
LIC (e.g. CVD less in rural areas of LIC, but more in some urban
areas of HIC)
• Urban and rural environments themselves evolve over time
– Rural  urban through economic developments and expansion of
cities to include neighbouring rural communities
– Urban  favourable or unfavourable environments
THE ABOVE CHANGES ARE ASSOICATED WITH MARKED SOCIETAL AND
LIFESTYLE CHANGES
TWO FUNDAMENTAL TENETS
1.
Obesity, Diabetes and CVD are Normal Biologic
Responses to Abnormal Environments
2.
Biologic factors are generally deterministic (and hence the
intervention strategies are more generalizable). Societal
factors have a more contextual impact ( and hence the
approaches to societal interventions may be more
variable.
Basis For PURE
• CVD burden is increasing globally and 80% occurs in L & MIC
– Increasing in LMIC
– Decreasing in HIC
• Epidemiologic transition has been hypothesized as
the cause, but has not been studied
• Key INTERHEART Study Observations
– >90% of AMI globally explained by 9 modifiable risk factors
– Similarity of impact in all regions and ethnic groups
So, What Causes These Risk Factors?
The Prospective Urban and Rural
Epidemiologic (PURE) study
3 interrelated levels of questions:
• Societal influences on health behaviours ,risk
factors and chronic diseases.
• Differences in health behaviours, risk factors and
disease between urban and rural settings;and their
variations in a range of countries at various levels of
economic advancement.
• Relationship of societal and individual level factors
on disease rates.
Hypothesis:
Maladaptation to urbanization is the
proximate cause of obesity, which leads to
elevated risk factors (dyslipidemia,
dysglycemia, hypertension). The risk factors
interact with genetic and psychosocial factors
resulting in increased CVD.
Scope
Primary area of interest:
• CVD, Diabetes and Obesity
Secondary goals: (high disease burden)
• Other chronic disease e.g. common cancers
• Infectious diseases e.g. TB
• Respiratory diseases e.g. COPD, asthma
• Injury and disability
• Depression
Objectives - Baseline
To Examine:
1. Urban-rural differences in
•
•
•
Levels of proximal exposures (built
environment,mechanization,activity, community structure,
urbanization, diet, food and tobacco policies and prices)
Prevalence of risk factors (conventional and emerging)
Prevalence of disease.
2. Clustering of the above within households,within
communities and within countries
Objectives: Longitudinal study
To determine:
1. whether changes in urbanization are associated with variations in
lifestyles and risk factors
2. how changes in individual (lifestyle) are affected by changes in
community level factors (eg. mechanization, access to health
care) are related to variations in risk factors and disease
rates/disability
3. how the above vary in different regions of a country or across
countries
4. predictors of disease.
5. to track risk factor changes and disease rates over time in the
communities studied.
Current Status of PURE
Countries actively recruiting:
India:
South Africa:
China:
22,000 subjects from 5 centres
Over 2000 individuals from one center
11,000 subjects from 10 locations.
Begun recruiting:
Colombia , Sweden and UAE
Ready to start:
Brazil, Argentina,Iran,
Sweden,Canada,Chile,Zimbabwe.
Other interested countries:
?Thailand, ?Russia,Tanzania, Poland.