1. National NCD Programmes:Challenge and the Way Forward - Experience in the industrializedcountries Prof. Jaakko Tuomilehto Department of Public Health, University of Helsinki, FinlandandCenter for Vascular Prevention,Danube-University Krems, Krems, Austria

2. Core Public Health Functions to prevent and control NCDs Evidence Action Health protection andassurance Action Health promotion Research Financing Training 3. Factors Contributing to Death Worldwide 10 global risk factors account for more than onethird of deaths worldwide Small number of risk factors cause high numberof premature deaths and large share of globalburden of disease Risk factors causing premature deaths include: high cholesterol - 4.4 million deaths (7.9% oftotal) tobacco - about 4.9 million deaths elevated blood pressure - 7.1 million deaths The World Health Report 2002. 4. Risk Factors for CVD and NCDs Modifiable Non-modifiable Smoking Personal history Dyslipidaemiaof CVD Raised LDL-C Family history Low HDL-C of CVD Age Raised triglycerides Gender Raised blood pressure Diabetes mellitus Obesity Dietary factors Thrombogenic factors Lack of exercise Excess alcohol consumption 5. Relationship Between Cholesterol andCHD Risk: Framingham Study150125 CHD incidence per 1000100 75 50 250 295(7.6) Serum total cholesterol, mg/dL (mmol/L) Castelli WP. Am J Med. 1984;76:412. 6. Most of the people dying from coronary heartdisease have intermediate level of a risk factor 7. SOUND COMBINATION OF THE POPULATION STRATEGY WITHHIGH RISK STRATEGY 1. Population strategy: - Greatest public health gains - Cost effective - Results also in other health benefits 1. High risk strategy: - Great benefits to the persons concerned - Effective use of health services 1612.09.12 8. Relationship of Serum Cholesterol to Mortality: Seven Countries Study 35 Northern EuropeDeath rate from CHD/1000 men 30 25United States 20 15 10Southern Europe, inland SerbiaSouthern Europe, Mediterranean5Japan0 2.603.25 3.90 4.505.155.80 6.45 7.107.75 8.409.05(100) (125) (150) (175) (200) (225) (250) (275) (300) (325)(350)Serum total cholesterol, mmol/L (mg/dL) Verschuren WM et al. JAMA 1995;274(2):131136. 9. Levels of Risk Associated with Smoking,Hypertension and Hypercholesterolaemia Hypertension (SBP 195 mmHg) x3x4.5 x9 x16 x1.6x6x4 Smoking Serum cholesterol level(8.5 mmol/L, 330 mg/dL) 10. Prospective Studies Collaboration Lancet 2007; 370: 1829-39 Established chiefly to investigate associations ofblood pressure and cholesterol with cause-specificmortality Individual data on 900 000 participants without anyprevious history of vascular disease from 61prospective cohort studies > 55 000 vascular deaths (34 000 ischaemic heartdisease [IHD], 12 000 stroke, 10 000 other) 150 000 participants from 23 studies also had HDLcholesterol (5000 vascular deaths) 11. IHD mortality (33 744 deaths) versus usual total cholesterolIHD mortality (33 744 deaths) versus usual total cholesterolAge at 1 mmol/L risktotal cholesterol80-8915% risk70-7918% riskUsual total cholesterol (mmol/L)60-6928% risk50-5942% risk40 50 60 70 8040-4956% risk 256 128 05 6432 168421CI)(floating absolute risks & 95%Hazard ratio 12. IHD mortality (33 744 deaths) versus usual total cholesterolIHD mortality (33 744 deaths) versus usual total cholesterolby BMIby BMI Age atBMINo. ofrisk(kg/m2) deaths 70-89 30+ 2369 077 (073-081)25-29 7198078 (075-080)30 kg/m26 5 4SBP >140mmHg2.0 (1.0 - 3.8)3.03 31.37 2 1Cholesterol 1.9 (1.0 - 3.5)1 0 1 23 0>6.5 mmol/l Number of risk factors present Adjusted for sociodemographic factors.Kivipelto et al., Arch Neurol 2005 43. ApoE4 Magnifies Effects of Lifestyle for the Risk of Dementia APOE 4 non-carriers Active Sedentary APOE 4 carriers Physical activity Active Sedentary 5.5IVIIIIII PUFA intake- IV quartilesIIIII4I5IIIIII SFA intake - quartiles IV I II 7.1 III IV7.1Non-drinkersInfrequentFrequent AlcoholNon-drinkers drinking InfrequentFrequent 3.8Non-smokersSmokers SmokingNon-smokersORs for dementiaSmokers3.2 44. Value of primordial or primaryprevention strategies in the USA 45. Value of primordial or primaryprevention strategies in the USA