German perspective

German perspective H. il. Kliir A number of studies focusing on cholesterol and coronary heart disease have been carried out or are in progress in what was formerly West Germany. They include the Monitoring Trends and Determinants in Cardiovascular Disease project, the Prospective Cardiovascular Mttnster Study, the Turkish Risk Factor Detrxtion and Intervention Program and the Deutsctles Herz-F’mgramm Study. The study of the Deutscbes Herz-Programm is a multiregional study, centring on major urban areas such as Berlin and Bremen, but also on other areas such as rural Bavaria. The study of the Deutsches Herz..Programm ~howa that up to 30% of both men and women in the older age gmups are hypertensive. Almost half of all young men smoke, and the prevaience of smoking in young women is also high. Some 60% of men aged SO-59 years have a body weight of more than 10% above normal; a similar incidence of ohsity is seen in women aged 60 years or more. Fat accounts for 35-40% of dietary energy. Alcohol is also an important source of calories, especially in young men, where it may account for up to 5% of daily calories. Fat consumption in Germany showed a steep rise from the late 1940s up to the 1980s. which was paralleled by an increase in myocardial infarctions. The increase in fat consumption was largely due to increased intake of meat and dairy products, encouraged by uationa! agricultora! po!icies. Today, 40% of middle-aged and older men have serum cholesterol levels of above 250 mg/dl (6.5 mmolll). Women show a different pattern, with a sharp rise in cholesterol !evels io the early 5Os, accompanied by a rise in coronary heart disease. A Bavarian study currently in progress aims to screen about 1 million people, either opportunistically, or via public screening, thus raising local awareness of the problem. The average serum cholesterol values for women io this studv aaed Ml-65 years are even higher than those f& men of the same age. underlining the increased risk in post-menopausal women, which is often overlooked in preventive pmgrammes.

Interesting data has also been obtained from immigrant groups, many of whom came to work in Germany in the 1960s. Of 3 million of these so-called ‘foreign citizens’, 1.5 million are of Turkish origin. Over the last 2 or 3 years it has become apparent that this population is at eoormous risk of coronary heart disease, with very high low-density lipoprotein and extraordinarily low high-density lipoprotein values. The reasons for this are not known, but it appears that both genetic and environmental factors play a part. Tbe pressure for cholesterol control in Germany comes from private organizations, rather than from government health agencies. A national cholesterol proposal for action has been published, based on the guidelines of the European Atherosclerosis Society and the U.S. National Cholesterol Education Program. Activities include the foundation of Lipid Leagues, which wilt carry out coordinated programrues with other organizations, such as the Hypertension League and Heart Foundation. A national risk factor screening programme ‘Check-up 35’ was initiated in 1989, which aims eventually to screen ail mea and women aged 35 years or older every 2 years in the primary care setting. The programme was initiated as a result of consensus between the insurance companies and the medical community. Screening will include a physical examination and laboratory work-up for metabolic, cardiovascular and renal disease. Detected abnormalities, including plasma cholesteml values greater than 200 mg/dl (5.2 mmolil), will be followed up and tnated. These activities have been carried out in the face of apparent indifference to cholesterol on the part of the government, hesitant support from the German cardiology community, and active opposition fmm the agricultural lobby.

Former-GDR perspective M.Hanefeld The division of Germany after the Second World War offers a unique opportunity to study the impact of environmental and social influences on