Public health and lifestyle interventions to reduce vascular ageing

Vera Simovska, MD., PhD, researcher, HEPA Macedonia National organization for the promotion of
Health-Enhancing Physical Activity, Republic of Macedonia
E-mail: hepa@makedonija.com

The greatest disease burden in Europe comes from noncommunicable diseases (NCD’s), especially
vascular diseases in general, and coronary, cerebral and peripheral arteries diseases in particular.
Cardiovascular disease (CVD) is causing more than half of all deaths across the WHO European
Region. Heart disease and stroke are the leading cause of death in all countries. The number of deaths
due to CVD reaches 4.4 million per year in Europe and 1.9 million per year in the EU. The burden on
the EU economy is 169 billion euros per year.

Many years ago, numerous clinical-epidemiological studies here and abroad showed that
atherosclerosis, the main ethiopatogenic process of vascular diseases is caused by many endogen and
external risk factors (RF) divided in two groups: a “major” RF (arterial hypertension,
hyperlipoproteinemia, smoking and T2DM) and other secondary, less important, the “minor” group
(obesity, physical inactivity, stress, age, family history of premature coronary disease, and ethnic
characteristics). Risk scoring systems were developed from long-term observational studies such as the
Framingham study, however that type of scoring provides an estimate of global cardiovascular risk.
A survey of 246 suggested coronary RF’s (Hopkins P.N., Williams R.R., 1981) and their role in
pathogenesis of atherosclerosis diseases were confirmed as multifactor etiology of CVD. A final
conclusion was that CVD risk could be estimated by continuous and successive following of all
relevant RF’s. This pioneering decision was focused on atherogenesis starting from childhood which
made it a pediatric nutritional problem (Holmann R, 1983).

Absolute risk leads to the identification of individuals who should be monitored and advised on risk
factor reduction. Absolute risk, however, increases with age, despite low cholesterol, low blood
pressure, and a no-smoking habit. Individual estimation of every RF and their interaction determines
the risk of CVD.

Much more was done during the next 30 years on athrosclerotic RF examination for CVD’s.
In accordance to the WHO Europe, eight leading RF’s are the main contributors to the burden of ill
health. Lifestyle and biological RF’s for CVD, accumulated throughout the life course have economic,
social, gender, political, behavioral and environmental determinants. There is increasing evidence that
societal determinants are as important as biological RF. From public health perspective, it is of key
importance to prevent rather than treat a CVD through surveillance of cases, the promotion of healthy
behaviors and healthy societies for the poor as well as to promote lifestyle interventions to reduce
biological RF.

CVD prevention remains an important issue in public health and preventive cardiology. Classic RF’s
for development of CVD are those associated with modifiable lifestyle such as unhealthy diet, physical
inactivity, tobacco use and harmful use of alcohol. Others include biological, preventable RF’s such as
blood pressure, serum lipoprotein level, hyperglycemia, overweight/obesity and low cardio respiratory
fitness-VO2max.

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Integration of Genomics into public health care is a new form of preventive medicine. To identify
genetic factors, which determine the risk of CVD, its function or a preclinical disease in order to gain
better insight into causal mechanism is an innovative genomic-based health care branch.

As societies across the world are ageing, there is a growing recognition of the value and importance of
providing quality care for older adults. In almost every country, the proportion of people aged over 60
is growing faster than any other age group, as a result of both longer life expectancy and declining
fertility rate.

So far, not so sufficient studies have been made on the negative influence and consequences on the
population health. Some negative influences include worsening of the social, economic factors and
living conditions as well as an increase of the psychosocial stress. These especially pertain to the
elderly people in general.

In a changing Europe, the EU needs a dynamic response towards an ageing population: a need to
increase healthy life years in accordance to the EU Public Health Strategy, 2008-2013. Core issue of
the EU Strategy is “To improve the health of EU citizens”: health promotion and diseases prevention,
inequalities and ageing. The second frame of the Strategy is “Health in all policies”: regional and
health development (tobacco, diet/nutrition, physical activity and alcohol).

Multisectoral action/commitment between European Commission/EU, the WHO Europe, national

governments and other stakeholders in reducing the incidence of diseases, disability and the effects of
ageing has been practiced and proven successful. Traditional approaches to health promotion and CVD
prevention are focused on lifestyle changes, screening, monitoring and evaluation.

Due to the chronic nature of CVD, the potential for the control of the problem lies in primary
prevention. Healthy diet, increased physical activity and smoking cessation are key determinants of
public health preventive action. North Karelia project was pioneering in CVD mortality changes in
Finland from 1969 to 2009. Up to 80% of CVD and up to 90% of T2DM are avoided through changing
lifestyle factors. Major changes in rates of CVD and T2DM can be seen in a few years (From North
Karelia to National Action: Puska P. et all, Helsinki 2009). To reduce CVD’s, the WHO suggests an
approach that emphasizes primary care, multisectoral action and community participation on a national
level through CINDI programme, a network of European countries and Canada.

A new approach on an EU ageing strategy and research on molecular basis will set-up a high profile
agenda for future health policy. One new marker of vascular aging is telomere length, as regulated by
telomerase enzymatic activity. Cross-sectional studies have illustrated the complex associations
between telomere length and clusters of cardiovascular risk factors, including hypertension,
dyslipidemia, obesity and smoking, as well as unhealthy lifestyle in general. It is of great notice to
further clarify the interaction between genetic and environmental influences on the aging process in
general. Behavioral genetics is a new form of research focused on effects of lifestyle interventions on
telomarase activity and telomerase length as independent RF’s for vascular ageing and the biomarker of
ageing. Future studies will hopefully shed light on the potential to stop or reverse vascular ageing, and
influence telomere biology.

Public health intervention programme that aims to bring about identifiable outcomes to the elderly
population includes genetic predisposition, environmental and lifestyle factors.