Transcript INCREASING GLOBAL BURDEN OF CARDIOVASCULAR DISEASE

INCREASING GLOBAL BURDEN OF
CARDIOVASCULAR DISEASE: CONTRIBUTIONS OF
METABOLIC SYNDROME
Charles H. Hennekens, MD
Sir Richard Doll Research Professor of Medicine
Charles E. Schmidt College of Medicine
Florida Atlantic University (FAU)
Clinical Professor of Preventive Medicine
Nova Southeastern University
Voluntary Professor of Family Medicine and Community Health
University of Miami Miller School of Medicine (UMMSM)
Disclosure
•I
am funded by the Charles E. Schmidt College of Medicine at Florida Atlantic
University (FAU). I have served as Principal Investigator on two investigator
initiated research grants funded to FAU by Bayer testing the effects of aspirin dose
on platelet and inflammatory biomarkers as well as nitric oxide formation.
•I serve as an independent scientist in an advisory role to investigators and
sponsors as Chair of Data and Safety Monitoring Boards for Actelion, Amgen,
Anthera, Bristol-Myers Squibb, and Sunovion and as a Member of Data and Safety
Monitoring Boards for AstraZeneca, Bayer , British Heart Foundation, Canadian
Institutes of Health Research and Lilly.
•I serve as an independent scientist in an advisory role to the U.S. Food and Drug
Administration, U.S. National Institutes of Health, Children's Services Council of
Palm Beach County and UpToDate.
•I serve as an independent scientist in an advisory role to legal counsel for
GlaxoSmithKline and Stryker.
•I serve as speaker for the Association for Research in Vision and Ophthalmology,
Baptist Health South Florida, National Association for Continuing Education,
PriMed, and the International Atherosclerosis Society.
•I receive royalties for authorship or editorship of three textbooks.
•I receive royalties as co-inventor on patents concerning inflammatory markers
and cardiovascular disease which are held by Brigham and Women’s Hospital.
•I have an investment management relationship with The West-Bacon Group
within SunTrust Investment Services who has discretionary investment authority.
•I do not own any common or preferred stock in any pharmaceutical or medical
device company.
LIFE EXPECTANCY AT BIRTH
•
•
US AND RICH COUNTRIES: 77 YEARS (73
IN MEN AND 81 IN WOMEN
POOR COUNTRIES: 50 YEARS (46 IN MEN
AND 54 IN WOMEN)
Heart Disease In The United States
•
•
•
Chief cause of death among men age 45 years
and older
Chief cause of death among women age 65
years and older
Responsible for 1 in 3 deaths in men and
women, or ~750,000 fatalities each year
Change In Age-Adjusted Mortality
1979 - 1995
10
Noncardiovascular Disease
0
-10
-20
%
Decline -30
Coronary Heart Disease
Stroke
-40
-50
-60
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95
National Center for Health Statistics.
Postulated Reasons For
Decreasing CHD Mortality
Treatment of Acute MI
•  in case fatality rate (30%  5%-10%) for
hospitalized MI
•  in utilization of:
 aspirin
 thrombolytics
 -blockers
 ACE inhibitors
Hennekens. Circulation. 1998;97:1095.
Postulated Reasons For
Decreasing CHD Mortality
Secondary prevention after MI
• Therapeutic Lifestyle Changes (TLC)
• Increase in utilization of:
–
–
–
–
aspirin
-blockers
ACE inhibitors
Statins (HMG-CoA reductase inhibitors)
Postulated Reasons For
Decreasing CHD Mortality
Primary prevention
•  in smoking(>50%  <25%)
•  in treatment of hypertension(16%  55%)
•  in treatment of hypercholesterolemia (target
230  200)
Hennekens. Circulation. 1998;97:1095.
Trends Among US Adolescents
Cigarette smoking
Body mass index
Physical Inactivity
Type II diabetes
Hennekens. Circulation. 1998;97:1095.
Shifting Worldwide Burden Of Disease
1990
All Other
25.5%
2020
Cancer
11.9%
All Other
33.2%
Cancer
18.0%
CVD
28.4%
Communicable,
Perinatal, Nutritional
34.2%
Communicable,
Perinatal, Nutritional
15.1%
Murray and Lopez. The Global Burden of Disease. 1996.
CVD
33.7%
Increasing Worldwide Burden
Of Cardiovascular Disease
1990
2020
Years Of Life Lost
4th
1st
Premature Death And
Disability
5th
1st
Conclusion
Based on these considerations the World
Health Organization has projected that within
the next decade cardiovascular disease will be
the leading cause of death and disability in the
world
Reasons For Worldwide Increase
In Cardiovascular Disease
Malnutrition
Infection
Smoking
BMI
Metabolic Syndrome
Any 3 of the Following 5 Criteria
•
Obesity
–
•
High density lipoprotein cholesterol (HDL-C)
–
•
•
•
Waist greater than 40 inches in men or
35 inches in women
Less than 40 mg/dL in men
50 mg/dL in women
Triglycerides greater than 150 mg/dL
Blood pressure greater than 130 mm Hg systolic or
85 mm Hg diastolic
Fasting blood glucose greater than 110 mg/dL
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults. JAMA. 2001;285:2486-2497.
Metabolic Syndrome
•
•
•
•
“The U.S. is the fattest society in the world and likely
to be the fattest in the history of the world”. (CH
Hennekens, NY Times 1/1/99)
Obesity is associated with dyslipidemia,
hypertension, and insulin resistance which has been
termed metabolic syndrome.
In the U.S. 40% of adults aged 40 and older have
metabolic syndrome.
Patients with metabolic syndrome have a 10 year risk
of a first CHD event of 16-18%.
Importance of Assessing Multiple Risk
Factors for CHD
+ Hypertension
+ Hyperglycemia
CHD Risk per 100 (10 y)
30
+ Low HDL-C
No other RF
+ Smoking
25
20
15
10
5
0
<100
100-129
130-159
160-189
LDL cholesterol (mg/dL)
≥190
Prevalence of the
Metabolic Syndrome by Race
40
35
White
African American
Hispanic
Other
Prevalence (%)
30
25
20
15
10
5
0
Men
Women
Data presented as % (SE)
Adapted from: Ford ES. JAMA. 2002;287:356-359.
New-onset Diabetes, A CHD Risk Equivalent,
as Correlated With the Number of
Characteristics of the Metabolic Syndrome
14
No. of MetS risk factors:
12
% With event
10
4/5
RR
3
2
1
0
24.4
8
6
7.26
4
4.50
2.36
2
1.00
0
0
1
2
3
Years
4
5
6
RR: Relative risk
Adapted from: Sattar N, et al. Circulation. 2003;108:414-419.
Modifiable CV Risk Factors in
Patients with Type 2 Diabetes*:
Results from UKPDS 23
Position
Variable
P Value†
First
LDL–C
<0.0001
Second
HDL–C
0.0001
Third
A1c
0.0022
Fourth
Systolic BP
0.0065
Fifth
Smoking
0.056
CV = cardiovascular.
*Adjusted for age and gender in 2693 Caucasian patients with type 2 diabetes, with dependent variable as time to first
event.
†Significant for coronary artery disease (n = 280). P values are significance of risk factor after controlling for all other risk
factors in model.
Adapted from Turner RC et al. BMJ. 1998;316:823–828.
Diabetes and Cardiovascular Disease
•
•
•
Diabetes is a major risk factor for CVD and can be a
component to the metabolic syndrome which
markedly increases risks of CVD
The CARDS trial of diabetics in primary prevention
was terminated early due to a statistically extreme
37% reduction in the primary pre-specified outcome
The US National Cholesterol Education Program
(NCEP) III has elevated diabetes from a major risk
factor to a CHD risk equivalent and recommends
that all patients with diabetes should be treated as
aggressively as survivors of a CVD event (i.e., MI or
stroke).
COMETS: Rosuvastatin Has a Better Effect on the
Overall Lipid Panel Than Does Atorvastatin in
Patients With Metabolic Syndrome
LSM Change From Baseline (%) (SE)
6 Weeks
12 Weeks
Placebo
(n=78)
RSV
10 mg
(n=164)
ATV
10 mg
(n=155)
RSV
combined
(n=242)
ATV
10/20 mg
(n=155)
Total Cholesterol
-0.7% *
-31.9%
-28.1%*
-36.8%
-32.5% *
LDL-Cholesterol
-0.3% *
-42.7%
-36.6% *
-48.9%
-42.5% *
HDL-Cholesterol
1.1% *
9.5%
5.1% †
10.4%
5.8% †
Non-HDL-Cholesterol
-0.9% *
-40.6%
-35.3% *
-46.6%
-40.8% *
Triglycerides
-2.8% *
-19.1%
-20.9%
-22.9%
-25.2%
Stalenhoef AFH, et al. Eur Heart J. 2005;26: 2664–2672.
SE: standard error of the mean
*P < .001 vs. rosuvastatin at same time point
†P < .01 vs. rosuvastatin at same time point
COMETS Study:
Safety
•
•
Both treatments were well tolerated
At Week 12, the overall occurrence of adverse events was
similar in each group
– 22.2% with rosuvastatin 10 mg / 20 mg (n=158)
– 20.7% with atorvastatin 10 mg / 20mg (n=150)
– 24.0% with placebo / rosuvastatin 20 mg (n=75)
•
ALT/CK Changes
– Clinically important ALT (> 3x ULN) occurred in 1 patient with
rosuvastatin 10 mg / 20 mg
– CK was elevated (> 10x ULN) in 1 patient with atorvastatin 10 mg / 20 mg
– CK was elevated (> 10x ULN) with myalgia in 1 patient with
rosuvastatin 10 mg / 20 mg
Stalenhoef AFH, et al. Eur Heart J. 2005;26: 2664–2672.
MERCURY I: Measuring Effective Reductions in
Cholesterol Using Rosuvastatin Therapy
•
Objective
– To compare the effects of switching to low doses of
rosuvastatin from commonly used doses of atorvastatin,
simvastatin, and pravastatin on low-density lipoprotein
cholesterol (LDL-C) goal achievement in high-risk patients
•
Inclusion criteria
– A history of CHD or other established atherosclerotic
disease, type 2 diabetes, or a 10-year CHD risk >20%
– Fasting LDL-C 115 mg/dL (3.0 mmol/L)
– TG  400 mg/dL (4.5 mmol/L)
•
Primary end point
– Number (%) of patients reaching 1998 European LDL-C goal
at week 16
Stender S. Diabetes, Obesity and Metabolism. 2005;7:430–438.
Schuster H et al. study. Am Heart J. 2004; 147: 70.
Effectiveness of Rosuvastatin Versus
Other Statins in Patients With the
Metabolic Syndrome‡
LDL-C
Non-HDL-C
Total-C
TG
HDL-C
20
9.3
10
7.4 7.0
9.6
Change (%)
0
-10
-13.1
-20
-17.3
-20.1
-23.4
-23.9
-20.8
-26
-30
-40
-50
-36.5
-35.1
*
-46.7
-33.6
*
-32.3
-33.3
-31.7
*
*
-42.5
-44.5
†
-18.5
-26.9
*
*
-29.9
*
-24.8
*
-40.8
*
*
RSV 10 mg (n = 234)
ATV 10 mg (n = 222)
ATV 20 mg (n = 382)
SIM 20 mg (n = 239)
PRV 40 mg (n = 224)
Analysis performed on intention-to-treat population with last observation carried forward
‡ Post-hoc analysis
* P < .0001 vs. rosuvastatin from analysis of covariance
† P <.0125 vs. rosuvastatin from analysis of covariance
RSV: rosuvastatin; ATV: atorvastatin; SIM: simvastatin
Stender S. Diabetes, Obesity and Metabolism. 2005;7:430–438.
Patients meeting ATP III goals (%)
Percentage of Patients With the Metabolic
Syndrome Meeting ATP III LDL-C Goals While
Undergoing Treatment With Select Statins ‡
100
80
77
73
62 *
60
51 *
40
34 *
20
0
n = 234
n = 222
n = 382
n = 239
n = 224
RSV 10 mg
ATV 10 mg
ATV 20 mg
SIM 20 mg
PRA 40 mg
*P < .0001 vs RSV 10 mg
ATP III LDL-C goals are <4.1 mmol/l (160 mg/dL) in patients with no or one risk factor and no coronary heart disease (CHD); <3.4 mmol/l
(130 mg/dl) for patients with two or more risk factors and 10-year CHD risk of 20%; <2.6 mmol/l (100 mg/dl) for patients with CHD or CHD
equivalents – i.e.other atherosclerotic diseases, diabetes or multiple risk factors and a 10-year CHD risk of >20%.
‡ Post-hoc analysis
Goal achievement was analyzed by means of logistic regression
RSV: rosuvastatin; ATV: atorvastatin; SIM: simvastatin; PRA: pravastatin
Stender S. Diabetes, Obesity and Metabolism. 2005;7:430–438.
Hispanic Population Facts and Figures
•
Of the approximate 281 million people living in the
United States:
– 35.3 million Hispanics or Latinos (largest ethnic minority
population)
– Hispanic population is growing at a much faster rate
than the population as a whole (account for
approximately one-half of the 9.4 million residents
added to the US population since Census 2000)
– Hispanic population is expected to increase by nearly
67 million between the years 2000 and 2050 (188%
increase)
• Their share of the nation's population would increase from 12.6
% to 24.4%
U.S. Census Bureau. Population Fact Sheet 2000. Available at: http://factfinder.census.gov/
U.S. Census Bureau. Race and Ethnicity Fact Finder. Available at: http://factfinder.census.gov/
Hispanic Population Facts and Figures
• Although Hispanics are the largest
ethnic population in the United Sates
they are underserved in the health
care system
• Hispanics are less likely to seek and
receive healthcare services
Center for Disease Control. MMWR Weekly. 2004;40:937-941.
Prevalence of Cardiovascular Diseases Among
Hispanic-Americans and Non-Hispanic Whites:
The Type of Disease Determines LDL-C Goal
Hypertension
Dyslipidemia *
Diabetes
Prior MI
Mexican American
†
White, non-Hispanic
†
Stroke †
0
* 0-1 Risk Factor:
† 2+ Risk Factors:
‡ CHD or Risk Equivalent:
5
10
15
20
25
30
35
40
LDL-C Goal < 160 mg/dL
LDL-C Goal < 130 mg/dL
LDL-C Goal < 100 mg/dL
LDL-C Goal < 70 mg/dL is an option for patients at very high risk
Population (%)
Adapted from: Trends and Differences in Cardiovascular Health Among Mexican-American and Non-Hispanic White Populations.
Available at: http://www.pfizer.com/pfizer/download/health/pubs_facts_cvhealth.pdf.
Grundy, S. et al. Arterioscler Thromb Vasc Biol. 2004;24;1329-1330.
National Heart, Lung, and Blood Institute. Third Report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III):
Executive Summary. National Institutes of Health. Bethesda, MD; 2001. NIH Publication 01-3670.
MI: myocardial infarction
Prevalence and Dyslipidemia Associated
With the Metabolic Syndrome
Prevalence
(% population)*
Women
Men
Non-Hispanic White
22.8
24.8
African-American
25.7
16.4
Mexican-American
35.6
28.3
Other
19.9
20.9
Dyslipidemia associated with the Metabolic Syndrome
- Low high density lipoprotein (HDL) cholesterol values –
-Increased low density lipoprotein (LDL) values –
- Raised apolipoprotein (Apo) B values –
- Increased flux of free fatty acids –
- Raised TG values -
* NHANES 1999-2000 data
Cossrow N and Falkner B. The Journal of Clinical Endocrinology & Metabolism. 2004;89:2590–2594.
Kolovo GD. Postgrad Med J. 2005;81;358-366.
Traits Associated with the Metabolic
Syndrome by Racial Categories
50
White
African American
Mexican American
Other
Prevalence (% population)
45
40
35
30
25
20
15
10
5
0
Large Waist
High TG
Low HDL-C
High BP
High
FPG/DM *
* CHD Risk Equivalent
LDL-C Goal < 100 mg/dL, < 70 mg/dL
is an option for patients at very high risk
DM – Diabetes mellitus
Meigs J. Am J Manag Care. 2002;8:S283-S292.
Trends in Serum Cholesterol Among
Adults 20 Years of age and Older by
Race/Ethnicity
NHANES 1988 - 1994
NHANES 1999 - 2002
250
Mean serum total
cholesterol (mg/dL)
206
204
204
200
199
205
202
150
100
50
0
Non-Hispanic White
Non-Hispanic Black
Heart Disease and Stroke Statistics - 2006 Update. Circulation. 2006;113:e85-e151.
Mexican American
Screening and Awareness of Dyslipidemia
Among Non-Hispanic Whites and MexicanAmericans*Mexican American
Hon-Hispanic Whites
Percent of Patients
70
66
65
60
50
48
42
40
30
20
10
0
Screened for high blood
cholesterol level during the
preceding 5 years
Were aware of high blood
cholesterol level †
* Individuals 20 years of age and older
† % ever told by their health care practitioner that their cholesterol was high, among those
with a high blood cholesterol test result, and those who used cholesterol lowering medication.
Adapted from: Centers for Disease Control. MMWR Morb Mortal Wkly Rep. 2005;54:117-119.
Understanding the Need for Chronic
Treatment with Lipid-lowering Medications
Respondents (%)
50
44 *
40
28
30
27
20
20
10
0
Whites
Blacks
Englishspeaking
Hispanics
Non-Englishspeaking
Hispanics
*P < 0.01 vs Blacks and Hispanics (English and non-English speaking)
Kaplan R. Cardiology in Review. 2006;14:1-6.
Statin Therapy in a Hispanic-American
Population With Hypercholesterolemia:
STARSHIP Trial - Background
•
Hispanic individuals:
– Evidence suggests that they are less frequently screened for
cholesterol levels
– Should have their lipids managed in the same fashion as nonHispanic white patients (ATP III Panel)
– Achievement of lipid-lowering goals is suboptimal
– Have been underrepresented in clinical trials of lipid-lowering
therapies and therefore the safety and efficacy of statin-based
lipid-lowering therapy have not been well characterized
Lloret, R. Am J Cardiol. 2006;98:768-773.
Statin Therapy in a Hispanic-American
Population With Hypercholesterolemia:
STARSHIP Trial - Endpoints
• Primary endpoint
– Percentage change from baseline in LDL-C at 6 weeks
• Secondary endpoints:
• Proportion of patients reaching NCEP ATP III lipid goals (LDL-C goals
overall and by risk category)
• Patients with baseline TG ≥ 200 mg/dL reaching LDL-C and non-highdensity lipoprotein cholesterol [non-HDL-C] goals
• Percentage change from baseline in other lipid measures and lipid ratios
at 6 weeks, including total cholesterol (TC), apolipoprotein (Apo) B, nonHDL-C, TG, HDL-C, Apo A-I, and LDL-C/HDL-C, TC/HDL-C, non-HDLC/HDL-C, and Apo B/Apo A-I ratios
• C-reactive protein (CRP) levels at baseline and after 6 weeks
• Safety evaluation included monitoring of adverse events; laboratory
evaluation, including clinical chemistry, hematology, and urinalysis;
assessment of vital signs; and physical examination
Lloret, R. Am J Cardiol. 2006;98:768-773.
Overall Changes in Lipid Panel with 10 mg of
Rosuvastatin and Atorvastatin After 6 Weeks
LDL-C
LS Mean Percent
change at 6 Weeks
10
HDL-C
+ 5.5%
TG
Non-HDL-C
+ 3.5%
0
-10
-14%
-20
-20%
-30
-33%
-36%
-40
-41%
-50
-45%
Rosuvastatin 10 mg (n=174)
Atorvastatin 10 mg (n=161)
P < .0001
P < .0001
LS Mean – Least square mean
Lloret, R. Am J Cardiol. 2006;98:768-773.
Overall Changes in Lipid Panel with 20 mg of
Rosuvastatin and Atorvastatin After 6 Weeks
LDL-C
LS Mean Percent
change at 12 Weeks
10
HDL-C
TG
Non-HDL-C
+5.7% +4.3%
0
-10
-20
-18%
-22%
-30
-40
-39%
-42%
-50
-50%
-45%
Rosuvastatin 20 mg (n=167)
Atorvastatin 20 mg (n=161)
-60
P < 0.01
P < .0001
LS Mean – Least square mean
Lloret, R. Am J Cardiol. 2006;98:768-773.
Overall Efficacy of Rosuvastatin and
Atorvastatin on Goal Attainment
100
Percent achieving
LDL-C target
88.0
78.0
80
73.0
60.0
60
40
20
0
RSV 10 mg RSV 20 mg
(n = 174)
(n = 167)
ATV 10 mg ATV 20 mg
(n = 161)
(n = 161)
P=.0002 CRESTOR 10 mg vs atorvastatin 10 mg,
Baseline LDL-C in the overall study population ranged from 159 – 165 mg/dL
P=.0212 CRESTOR 20 mg vs atorvastatin 20 mg.
RSV: rosuvastatin
ATV: atorvastatin
P = .1726 CRESTOR 10 mg vs atorvastatin 20 mg.
Lloret, R. Am J Cardiol. 2006;98:768-773.
Percent achieving LDL-C target
Efficacy of Rosuvastatin and Atorvastatin
on Goal Attainment : High Risk Subgroup
100
91
80
74.1
62
60
52
40
20
0
RSV 10 mg
RSV 20 mg
ATV 10 mg
ATV 20 mg
(n = 116)
(n = 106)
(n = 106)
(n = 106)
High Risk Patients:
P=.001 vs atorvastatin 10 mg,
NS=CRESTOR 10 mg vs atorvastatin 20 mg.
P<.0001 vs atorvastatin 20 mg.
Lloret, R. Am J Cardiol. 2006;98:768-773.
(LDL-C Goal < 100 mg/dL)
Baseline LDL-C in the overall study population ranged from 159 – 165 mg/dL
§ Retrospective analysis
RSV: rosuvastatin
ATV: atorvastatin
Adverse Events
Rosuvastatin
Atorvastatin
10 mg
20 mg
10 mg
20 mg
(n = 183)
(n = 172)
(n = 167)
(n = 170)
30%
30%
32%
31%
Leading to death
0.0%
0.0%
0.0%
0.0%
Leading to study
discontinuation
2.2%
4.1%
1.8%
1.2%
Serious adverse events
1.1%
0.6%
2.4%
1.2%
Parameter
Any Adverse Event
Lloret, R. Am J Cardiol. 2006;98:768-773.
Hypercholesterolemia
in Hispanic-Americans Summary
•
•
•
Hispanic-Americans make up approximately 12.5 % of the
United States population
– Largest minority population
Hypercholesterolemic Hispanics are under-identified and
under-treated compared to non-Hispanic Whites
Hispanic individuals are:
– Less frequently screened for cholesterol levels
– Less adequately controlled than other US populations
– Underrepresented in clinical trials of lipid-lowering
therapies
U.S. Census Bureau. Race and Ethnicity Fact Finder. Available at: http://factfinder.census.gov/ .
U.S. Census Bureau. Population Fact Sheet 2000. Available at: http://factfinder.census.gov/.
Ford ES. Circulation. 2003;107:2185-2199.
CDC. Morb Mortal Wkly Rep. 2005;54:117-119.
Lloret, R. Am J Cardiol. 2006;98:768-773.
Hypercholesterolemia
in Hispanic-Americans Summary (cont.)
•
•
•
Since Hispanic individuals have been traditionally
under-represented in clinical trials employing the use
of lipid-lowering therapies, the safety and efficacy of
statin therapy in Hispanic patients have not been well
characterized
Rosuvastatin therapy (10 and 20 mg/day) enabled
hypercholesterolemic Hispanic patients to achieve
significantly greater reductions in LDL-C and nonHDL-C than did milligram equivalents of atorvastatin
Single agent therapy with rosuvastatin as well as
atorvastatin enabled the majority of patients to reach
NCEP ATP III LDL-C goals
Lloret, R. Am J Cardiol. 2006;98:768-773.
NCEP III RECOMMENDATIONS
•Statins are the first line agents
for virtually
all patients requiring lipid modification by
drugs
•Single agent therapy with rosuvastatin as
well as atorvastatin enable the majority of
patients to reach NCEP ATP III LDL-C goals
•Nicotinic acid, fibrates, omega-3 fatty acids
or ezetimibe may be considered as adjunctive
therapies, not alternatives for high-risk
patients with residual high TG or low HDL-C
Randomized Evidence For Lipid Modifying
Drugs On Clinical Outcomes
•
•
•
Statins
Nicotinic Acid ~
2800
Fibrates
– Gemfibrozil
– Fenofibrate
•
•
~ 90000
~
~
2500
10000 (p=ns)
Omega-3-FA ~ 11000
Ezetimibe
0
French Fries
20 years ago
210 calories
2.4 ounces
Today
610 calories
How many
calories are
ounces
in6.9
these
fries?
Calorie difference: 400 Calories
How to burn* 400 calories:
Walk 2 hour 20 minutes
*Based on 130-pound person.
Darwinism and Risk
of Cardiovascular Disease
Walking the Dog
Established Risk Factors for CHD
Blood cholesterol
10%  = 20%-30%  in CHD
High blood pressure
5-6 mm Hg  = 42%  in Stroke
= 16%  in CHD
Cigarette smoking
Cessation = 50%-70%  in CHD
Body weight
BMI<25 vs BMI>27 = 35%-55%  in CHD
Physical activity
20-minute brisk walk daily = 35%-55%  in CHD
CHIEF AVOIDABLE CAUSES OF
PREMATURE DEATH IN THE US
•
•
•
•
•
•
CIGARETTES
OBESITY
PHYSICAL INACTIVITY
LIPIDS
BLOOD PRESSURE
HEAVY ALCOHOL CONSUMPTION
“We must all hang together, or assuredly
we shall all hang separately.”
– Benjamin Franklin
July 4, 1776