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28/03/2011 Risk factor monitoring in Europe 1
Chronic disease risk factor monitoring in Europe
Kari Kuulasmaa, Research Professor, THL
CHD mortality, Men aged 35-64
1950
1952
1954
1956
1958
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
0
100
200
300
400
500
600
700
/100 000
KTL/ETEO/HT/2004 Data source: WHO Mortality Database Age standardized to European standard population
FIN
USA
RUS
HUNUK
SWE
SPA
FRAJPN
28/03/2011 Risk factor monitoring in Europe 3
Population level risk factor monitoring
• Registry data
– Not very useful
• Questionnaire surveys
– Self-reported information
– Cheaper than examination surveys
• Examination surveys
– Only source for many risk factors
– Objective information
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Interview /questionnaire surveys (HIS)
• CINDI health monitor
– Health knowledge, attitudes and behaviour
• European Health Interview Survey (EHIS)
– Piloting and first round 2005-
– All EU countries 2014-
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Contents of EHIS
• Background variables
• Health status
• Health care– Measurement of blood pressure, cholesterol, glucose
– Cancer screening
• Health determinants– Weight, height
– Physical activity
– Consumption of fruit and vegetables
– Environmental exposures
– Smoking
– Alcohol
– Drugs
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Health Examination Surveys (HES)
• National surveys from early 1960s, increasing in numbers
• WHO MONICA Project 1980s-1990s– www.ktl.fi/monica
• European Health Risk Monitoring (EHRM) Project– Updated the MONICA protocol in 2002
– www.ktl.fi/ehrm
• European Health Examination Survey (EHES)– Feasibility study in 2006-2008
• www.ktl.fi/fehes
– Implementation 2009-• www.ehes.info
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7
History of HESs in Europe
1960 1970 1980 1990 2000
Finland
Sweden
Norway
Netherlands
West Germany
Germany
UK -England
UK -Scotland
Ireland
Poland
Denmark
RomaniaSpainCroatia
France
Czech Republic
28/03/2011 Risk factor monitoring in Europe 8
Health Examination Surveys (HES)
• National surveys from early 1960s, increasing in numbers
• WHO MONICA Project 1980s-1990s– www.ktl.fi/monica
• European Health Risk Monitoring (EHRM) Project– Updated the MONICA protocol in 2002
– www.ktl.fi/ehrm
• European Health Examination Survey (EHES)– Feasibility study in 2006-2008
• www.ktl.fi/fehes
– Implementation 2009-• www.ehes.info
28/03/2011 Risk factor monitoring in Europe 9
WHO MONICA Project
Multinational MONitoring of trends and determinants
in CArdiovascular disease
• Monitoring of cardiovascular disease mortality, morbidity, medical care and risk factors in different populations over a period of 10 years
• Assessment of the relationship between the trends observed in mortality, morbidity, risk factors and medical care
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WHO MONICA Project populations
The WHO MONICA Project Circulation 1994; 90(1):583-612
WHO MONICA Project Lancet, 1999; 353: 1547-1557 CORMORANT 2
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Prevalence of daily cigarette smoking (%).Age group 35-64, age standardized. Final survey.
CHN-BEIRUS-NOCRUS-NOIPOL-TAR
POL-WARYUG-NOSBEL-CHA
RUS-MOCGER-BREDEN-GLOBEL-GHERUS-MOISPA-CATUNK-GLACZE-CZESWI-TIC
GER-AUULTU-KAU
ITA-BRIFRA-LIL
CAN-HALFIN-KUOFIN-TULITA-FRI
UNK-BELFIN-NKASWI-VAF
GER-EGESWE-GOTGER-AURFRA-TOUAUS-PERFRA-STR
ICE-ICEUSA-STA
AUS-NEWSWE-NSWNEZ-AUC
0 20 40 60 80 100
MEN
DEN-GLOUNK-GLAPOL-WAR
ICE-ICEGER-BREYUG-NOSBEL-CHA
SWE-GOTSWE-NSWBEL-GHE
SWI-TICGER-AUUCAN-HALSWI-VAFUNK-BELCZE-CZE
ITA-BRIITA-FRI
FRA-TOUPOL-TARUSA-STAFIN-TULFRA-LIL
AUS-NEWGER-AURSPA-CATFRA-STRNEZ-AUCRUS-MOI
RUS-MOCFIN-KUO
AUS-PERFIN-NKA
GER-EGECHN-BEIRUS-NOI
RUS-NOCLTU-KAU
0 20 40 60 80 100
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 5
28/03/2011 Risk factor monitoring in Europe 12
10-year trend in percentage of daily cigarette smokers.
Age group 35-64, age standardized, with 95% confidence interval
USA-STAITA-BRI
FRA-TOUUNK-GLAFRA-STR
AUS-NEWGER-EGENEZ-AUCAUS-PERSPA-CAT
POL-WARCZE-CZE
SWE-GOTUNK-BELSWI-VAF
ITA-FRIFRA-LIL
GER-AURFIN-KUOSWI-TIC
LTU-KAUFIN-NKA
POL-TARICE-ICE
BEL-CHASWE-NSWRUS-MOCDEN-GLO
FIN-TULBEL-GHERUS-NOCGER-AUUGER-BREYUG-NOSRUS-MOICAN-HALRUS-NOICHN-BEI
-30 -20 -10 0 10 20 30
MEN
USA-STAUNK-BELNEZ-AUCUNK-GLA
ICE-ICECHN-BEI
AUS-PERAUS-NEWSWE-GOTGER-EGE
ITA-FRICAN-HAL
POL-WARFRA-STRDEN-GLOGER-BRELTU-KAUFIN-TUL
RUS-MOCRUS-MOI
SWE-NSWRUS-NOCFIN-KUOSWI-TIC
CZE-CZEFIN-NKA
GER-AURYUG-NOSFRA-TOU
FRA-LILSWI-VAF
ITA-BRIBEL-GHERUS-NOI
GER-AUUBEL-CHASPA-CATPOL-TAR
-30 -20 -10 0 10 20 30
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 4
28/03/2011 Risk factor monitoring in Europe 13
Mean systolic blood pressure (mmHg). Age group 35-64, age standardized. Final survey.
FIN-NKAGER-EGEFIN-KUOITA-FRIFIN-TUL
LTU-KAUCZE-CZEGER-AUUYUG-NOSGER-AURFRA-STRRUS-NOIUNK-BEL
FRA-LILAUS-PER
SWE-GOTPOL-TARRUS-MOIUNK-GLAPOL-WARSWI-VAF
GER-BRESWI-TIC
RUS-NOCCHN-BEI
AUS-NEWBEL-CHA
ITA-BRISWE-NSWRUS-MOCCAN-HALBEL-GHEUSA-STANEZ-AUCDEN-GLOFRA-TOU
ICE-ICESPA-CAT
100 110 120 130 140 150
MEN
FIN-KUOGER-EGE
FIN-NKAYUG-NOSRUS-NOIFIN-TULITA-FRI
LTU-KAUPOL-TARCZE-CZERUS-MOIRUS-MO
RUS-NOCGER-AUUCHN-BEISWE-GOUNK-BELGER-AUR
FRA-LILGER-BREPOL-WARAUS-NEWFRA-STR
ITA-BRIUNK-GLASWE-NS
CAN-HALAUS-PERBEL-CHASWI-VAFSWI-TIC
NEZ-AUCBEL-GHEDEN-GLO
ICE-ICEUSA-STASPA-CATFRA-TOU
100 110 120 130 140 150
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 7
28/03/2011 Risk factor monitoring in Europe 14
10-year trend in systolic blood pressure (mmHg).
Age group 35-64, age standardized, with 95% confidence interval
POL-WARGER-BRERUS-MOIFRA-STR
ITA-BRIFIN-KUO
RUS-MOCFRA-TOU
FRA-LILUNK-GLANEZ-AUC
FIN-TULSPA-CATSWI-TICITA-FRI
FIN-NKADEN-GLO
SWE-NSWCZE-CZEUSA-STA
AUS-NEWAUS-PERRUS-NOC
ICE-ICERUS-NOI
GER-AURPOL-TARSWI-VAFBEL-CHAYUG-NOSLTU-KAU
GER-EGECHN-BEI
GER-AUUUNK-BEL
SWE-GOTBEL-GHECAN-HAL
-20 -15 -10 -5 0 5 10 15
MENPOL-WARGER-BRERUS-MOIFRA-STR
RUS-MOCFRA-TOU
SWI-TICUNK-GLA
ITA-BRIFIN-KUOFRA-LILFIN-NKA
SPA-CATITA-FRI
USA-STADEN-GLO
SWE-NSWGER-AURSWI-VAFLTU-KAUFIN-TUL
CZE-CZERUS-NOCNEZ-AUCAUS-PERPOL-TARGER-EGEUNK-BEL
AUS-NEWBEL-CHABEL-GHEGER-AUURUS-NOIICE-ICE
SWE-GOTCHN-BEI
YUG-NOSCAN-HAL
-20 -15 -10 -5 0 5 10 15
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 6
28/03/2011 Risk factor monitoring in Europe 15
Mean total cholesterol (mmol/l).Age group 35-64, age standardized. Final survey.
SWI-TICYUG-NOSSWI-VAFSWE-NSICE-ICE
GER-AUUGER-BREBEL-CHACZE-CZE
GER-AURUNK-GLABEL-GHEFIN-NKA
FRA-STRFIN-KUOLTU-KAU
DEN-GLOITA-BRI
UNK-BELFIN-TULITA-FRIFRA-LIL
FRA-TOUGER-EGEAUS-NEWPOL-WARNEZ-AUCCAN-HALSPA-CATPOL-TAR
SWE-GOTAUS-PERUSA-STARUS-NOIRUS-MOI
RUS-MOCRUS-NOCCHN-BEI
4 4.5 5 5.5 6 6.5 7
MEN
LTU-KAUSWI-TIC
YUG-NOSGER-BRECZE-CZESWE-NS
BEL-CHAUNK-GLASWI-VAFICE-ICE
BEL-GHEGER-AURGER-AUUUNK-BELFRA-STR
ITA-BRIFRA-LIL
DEN-GLOGER-EGECAN-HALFIN-KUOFIN-NKAFIN-TULITA-FRI
POL-WARFRA-TOUAUS-NEWNEZ-AUC
RUS-MOCSPA-CATPOL-TARRUS-MOI
SWE-GOTRUS-NOIAUS-PERRUS-NOCUSA-STACHN-BEI
4 4.5 5 5.5 6 6.5 7
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 9
28/03/2011 Risk factor monitoring in Europe 16
FRA-LILRUS-NOCSWE-GOT
ITA-FRIRUS-MOIFIN-KUOCAN-HALFIN-NKAFIN-TUL
RUS-NOIRUS-MOCCZE-CZEBEL-GHEUNK-GLAAUS-PERSPA-CAT
GER-EGEUNK-BELSWI-VAFUSA-STAFRA-TOUGER-AUUGER-AURAUS-NEWLTU-KAUSWE-NS
DEN-GLONEZ-AUCBEL-CHA
ICE-ICEGER-BREPOL-WARPOL-TARCHN-BEIFRA-STR
ITA-BRIYUG-NOS
SWI-TIC
-1.5 -1 -0.5 0 0.5 1 1.5 2
MEN
10-year trend in total cholesterol (mmol/l).
Age group 35-64, age standardized, with 95% confidence interval
SWE-GOTRUS-NOC
FRA-LILFIN-NKAITA-FRI
RUS-NOIFIN-KUOFIN-TUL
RUS-MOIAUS-PERUNK-GLACZE-CZE
ICE-ICERUS-MOCUNK-BELNEZ-AUCGER-AUUGER-EGESPA-CAT
AUS-NEWFRA-TOUSWE-NS
DEN-GLOSWI-VAFCAN-HALGER-AURBEL-GHEUSA-STAPOL-TARLTU-KAU
POL-WARGER-BREBEL-CHACHN-BEIFRA-STR
YUG-NOSITA-BRI
SWI-TIC
-1.5 -1 -0.5 0 0.5 1 1.5 2
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 8
28/03/2011 Risk factor monitoring in Europe 17
AUS-NEWGER-AURCZE-CZECAN-HALFIN-NKA
FRA-STRFIN-KUO
YUG-NOSFIN-TUL
GER-AUUBEL-CHA
POL-WARLTU-KAU
GER-EGEUSA-STA
ITA-FRIICE-ICE
UNK-GLAGER-BRENEZ-AUCSPA-CATSWI-VAFSWI-TICITA-BRI
AUS-PERSWE-NSW
FRA-LILBEL-GHEUNK-BEL
SWE-GOTRUS-NOIFRA-TOUDEN-GLORUS-NOCPOL-TARRUS-MOI
RUS-MOCCHN-BEI
20 22 24 26 28 30
MEN
2
RUS-NOIRUS-NOCPOL-TARLTU-KAU
YUG-NOSCZE-CZECAN-HAL
POL-WARSPA-CAT
AUS-NEWFIN-KUOFIN-NKA
UNK-GLAGER-AURBEL-CHAUSA-STAGER-AUURUS-MOC
FRA-LILGER-EGERUS-MOIGER-BRE
ICE-ICEFIN-TUL
FRA-STRAUS-PERBEL-GHE
ITA-FRISWE-NSWNEZ-AUCUNK-BEL
ITA-BRISWI-TIC
SWE-GOTSWI-VAF
DEN-GLOFRA-TOUCHN-BEI
20 22 24 26 28 30
WOMEN
Mean Body Mass Index (kg/m ).Age group 35-64, age standardized. Final survey.
2
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 11
28/03/2011 Risk factor monitoring in Europe 18
RUS-MOISWI-TIC
RUS-MOCLTU-KAU
RUS-NOCFRA-STRGER-AUURUS-NOICZE-CZEDEN-GLO
FIN-TULSWI-VAF
GER-BREITA-FRI
POL-WARGER-AURFRA-TOUFIN-KUOUNK-BELGER-EGE
FRA-LILPOL-TARBEL-CHAYUG-NOSBEL-GHEFIN-NKA
CAN-HALSWE-NSW
SPA-CATAUS-PERCHN-BEI
SWE-GOTITA-BRI
NEZ-AUCICE-ICE
UNK-GLAUSA-STA
AUS-NEW
-4 -3 -2 -1 0 1 2 3 4
MEN
10-year trend in BMI (kg/m ). Age group 35-64, age standardized, with 95% confidence interval
2
RUS-MOCRUS-MOILTU-KAU
RUS-NOCCZE-CZE
ITA-FRIFRA-STRBEL-CHAYUG-NOSSWI-VAFRUS-NOIFRA-TOUBEL-GHEFIN-NKASWI-TICCHN-BEIUNK-BELGER-BREPOL-WARGER-AUR
SWE-NSWFIN-TUL
DEN-GLOITA-BRI
SPA-CATGER-AUUGER-EGESWE-GOTPOL-TARFIN-KUO
UNK-GLAFRA-LIL
NEZ-AUCAUS-PER
ICE-ICEAUS-NEWUSA-STACAN-HAL
-4 -3 -2 -1 0 1 2 3 4
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 10
28/03/2011 Risk factor monitoring in Europe 19
FRA-LILRUS-MOI
RUS-NOCFIN-KUO
RUS-MOCITA-FRI
FRA-TOUSWE-GOTUNK-GLAPOL-WAR
FIN-TULSPA-CATCZE-CZEFIN-NKA
GER-BREAUS-PERUSA-STANEZ-AUCGER-EGEFRA-STRSWI-VAF
AUS-NEWRUS-NOIUNK-BELLTU-KAUGER-AURDEN-GLOSWE-NS
CAN-HALITA-BRI
GER-AUUBEL-CHABEL-GHE
ICE-ICEPOL-TARCHN-BEI
YUG-NOSSWI-TIC
-0.6 -0.3 0 0.3 0.6
MEN
10-year trend in risk score. Age group 35-64, age standardized, with 95% confidence interval
RUS-MOIPOL-WARUNK-GLAGER-BRERUS-MOC
ITA-FRIFIN-KUOFRA-LILFIN-NKA
FRA-TOUAUS-PERUSA-STA
SWE-GOTNEZ-AUCUNK-BEL
RUS-NOCFIN-TUL
GER-EGEAUS-NEWDEN-GLOCZE-CZEFRA-STR
ICE-ICESWE-NS
SPA-CATRUS-NOISWI-VAF
GER-AURLTU-KAU
ITA-BRIBEL-GHEGER-AUUCHN-BEIPOL-TARBEL-CHASWI-TIC
CAN-HALYUG-NOS
-0.6 -0.3 0 0.3 0.6
WOMEN
WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 12
28/03/2011 Risk factor monitoring in Europe 20
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Health Examination Surveys (HES)
• National surveys from early 1960s, increasing in numbers
• WHO MONICA Project 1980s-1990s
– www.ktl.fi/monica
• European Health Risk Monitoring (EHRM) Project
– Updated the MONICA protocol in 2002
– www.ktl.fi/ehrm
• European Health Examination Survey (EHES)
– Feasibility study in 2006-2008
• www.ktl.fi/fehes
– Implementation 2009-
• www.ehes.info
28/03/2011 Risk factor monitoring in Europe
22
Results of FEHES
http://www.ktl.fi/fehes/
28/03/2011 Risk factor monitoring in Europe 23
European Health Examination Survey
• To provide info on health behaviour, health determinants, prevalence of diseases, met and unmet need for health services, functional limitations and nutritional status
• For planning and evaluation of health policies and health care, and for research
• Complementary to EHIS
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EHES target population
• Entire country
• Permanent residents, including institutionalized persons
• Core age group: 25-64 years
• Can extend to 18+
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EHES sampling
• Two stage sampling
• Sample of areas within the country
• Sample of individuals within the area
• Sample size
• At least 4000 persons
• About equal sample size for each area
• Equal sample size for each sex and age stratum
28/03/2011 Risk factor monitoring in Europe 26
Selection of HES measurements
• Based on:• Epidemiological and public health
criteria• Availability of international standards
• Existing recommendations:• ECHI list;• Other Projects of the Public Health
Programme;• EHRM; • WHO STEPS.
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Core measurements
Examinations Questions
• Height
• Weight
• Waist circumference
• Blood pressure
• Blood samples (non-fasting,e.g. for total-, HDL-cholesterol…)
• Fasting blood samples (e.g.for glucose)
• Age
• Sex
• Education
• [Occupation/income]
• General health/ generalhealth status
• CVD
• Hypertension
• Hyper/dyslipidemia
• Diabetes
• Smoking
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Additional measurements
Examinations Questions
• Hip circumference
• Ankle/brachial index
• Physical fitness test
• Lung function test
• Physical performance/ functional test (e.g. walking speed test, vision test, hearing test, hand grip test)
• Cognitive function test
• ECG
• Urine sample (glucose, cotinine)
• Saliva test (alternative for cotinine)
• Bone density
• Other items pertaining to research questions at local level
• Physical activity
• Drinking
• Use of health services (general)/ medication
• Social support
• Psychological distress
• Respiratory disease (e.g. COPD, asthma)
• Use of health services (for special conditions)
• Use of contraception and HRT
• Diet: fruit & vegetable consumption
• Mental health
• Oral health
• Other items pertaining to research questions at local level
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Criteria for inclusion
Inclusion
in
previous
national
HESs
Practicality Acceptability Low
cost
International
standards
availability
Clear
interpretation
of results
Height +++ +++ +++ +++ +++ +++
Weight +++ +++ ++ +++ +++ +++
WC +++ ++ ++ +++ +++ +++
BP +++ ++ ++ ++ +++ +++
Blood
sample
++ ++ + * +++ +++
Physical
fitness test
+ ++ ++ ++ + +
Lung
function test
+ ++ ++ ++ +++ ++
Physical
performance
+ ++ ++ +++ + ++
Cognitive
function test
++ ++ ++ +++ ++ ++
Urine
sample
+ ++ + * * *
Saliva
sample
+ ++ ++ * * *
ECG + + ++ + ++ ++
Bone
density
+ + ++ + ++ ++
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Setting up EHESPhase I
Setting up EHES RC
EHES Manual and national HES manuals
Training programme
Planning and preparing national HES, including a pilot survey in 13 countries
Phase I
I Full-size HES in 13 pilot countries
Planning and preparing national HES in rest of the European countries
Development to a sustainable HES system
0 4321
Funding from the DG Sanco
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Pilot countries
Finland
Germany
Netherlands
Poland
Czech Republic
Slovakia
Greece
Italy
MaltaSpain
Portugal
UK/England
Norway
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Comparability between surveys
within a country
between countries
Comparability with previous surveys
within a country
Training
Challenges for EHES
• Sampling frame and sampling
• Participation rate
• Quality of measurements
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