DAGLI STILI DI VITA AI FARMACI ( O DAI FARMACI AGLI STILI DI VITA?) Dr. Brunello Cappelli.

DAGLI STILI DI VITAAI FARMACI

(O DAI FARMACI AGLI STILI DI VITA?)

Dr. Brunello Cappelli

Prevalence of Overweight*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 81,3% 79,3% 75,8% 82,4% 71,0% 81,4% 70,5% 73,8% 76,8%

Survey 2 87,0% 78,4% 79,7% 82,7% 79,2% 71,7% 78,5% 78,7% 79,9%

Survey 3 84,6% 77,2% 77,1% 85,3% 85,6% 81,3% 78,9% 84,4% 82,7%

Czech Rep.

Finland France Germany Hungary ItalyNether-lands

Slovenia ALL

P=0.04

S2 vs. S1 : P=0.15S3 vs. S2 : P=0.22S3 vs. S1 : P=0.02

* Body mass index ≥ 25 kg/m²

Prevalence of Obesity*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 31,4% 29,6% 33,4% 23,0% 23,3% 22,4% 18,9% 19,2% 25,0%

Survey 2 40,1% 33,6% 37,5% 30,6% 36,8% 23,6% 28,2% 28,0% 32,6%

Survey 3 37,9% 26,4% 36,8% 43,1% 49,3% 29,4% 26,5% 39,1% 38,0%

Czech Rep.


Slovenia ALL

P=0.0006


* Body mass index ≥ 30 kg/m²

Prevalence of Central Obesity*

* Waist circumference ≥ 102 cm in men or ≥ 88 cm in women

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 49,7% 30,6% 54,6% 40,3% 44,8% 42,6% 42,9% 34,2% 42,2%

Survey 2 52,1% 48,3% 58,8% 46,8% 56,3% 55,4% 55,2% 52,6% 53,0%

Survey 3 56,1% 41,3% 54,8% 51,3% 65,6% 52,0% 56,0% 54,9% 54,9%

Czech Rep.


Slovenia ALL

P<0.0001

S2 vs. S1 : P=0.0001S3 vs. S2 : P=0.47S3 vs. S1 : P<0.0001

Prevalence of Diabetes*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 21,8% 15,4% 16,7% 13,5% 26,6% 17,2% 10,3% 17,4% 17,4%

Survey 2 21,5% 18,7% 27,5% 13,5% 21,1% 21,8% 13,2% 23,8% 20,1%

Survey 3 30,8% 19,1% 34,2% 22,6% 44,8% 21,7% 20,6% 18,8% 28,0%

Czech Rep.


Slovenia ALL

P=0.004


* Self-reported history of diagnosed diabetes

Therapeutic Control of Diabetes*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 38,7% 34,4% 15,1% 71,4% 48,6% 39,1%

Survey 2 29,9% 30,8% 20,4% 26,9% 42,3% 53,2% 70,7% 72,7% 42,1%

Survey 3 17,2% 40,0% 27,8% 18,7% 25,4% 10,2% 33,3% 20,0% 21,5%

Czech Rep.


Slovenia ALL

P=0.04


* Fasting glucose < 7 mmol/L in patients with history of diabetes

Prevalence of Smoking*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 22,0% 12,8% 25,0% 16,8% 23,3% 18,6% 31,8% 13,3% 20,3%

Survey 2 19,3% 21,6% 24,2% 16,8% 30,1% 15,1% 28,3% 14,6% 21,2%

Survey 3 22,2% 16,8% 24,8% 18,4% 18,3% 14,0% 15,1% 12,0% 18,2%

Czech Rep.


Slovenia ALL

P=0.64


* Self-reported smoking or CO in breath > 10 ppm

Prevalence of Raised Blood Pressure (1)*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 60,1% 56,1% 48,4% 58,4% 50,6% 55,3% 54,0% 55,1% 54,6%

Survey 2 46,9% 52,0% 55,5% 67,0% 40,4% 50,8% 54,4% 62,8% 54,0%

Survey 3 62,5% 67,1% 48,1% 50,9% 46,3% 60,5% 59,6% 55,1% 55,2%

Czech Rep.

Finland France Germany Hungary ItalyNether lands

Slovenia ALL

P=0.79


* SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg

Medication Use: ACE Inhibitors & Angiotensin II RA

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 28,1% 17,3% 33,8% 31,4% 46,3% 31,8% 27,4% 31,2% 31,0%

Survey 2 47,1% 31,0% 43,7% 50,6% 58,6% 53,5% 42,9% 63,0% 49,2%

Survey 3 76,1% 59,3% 78,9% 72,8% 80,6% 70,9% 66,5% 83,0% 74,6%

Czech Rep. Finland France Germany Hungary ItalyNether-

landsSlovenia ALL

P<0.0001

S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001

Medication Use: Beta-Blockers

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 65,3% 77,8% 56,3% 43,6% 57,7% 49,2% 46,8% 51,8% 56,0%

Survey 2 73,7% 87,9% 60,4% 68,1% 84,3% 61,2% 48,2% 65,7% 69,0%

Survey 3 91,3% 95,8% 74,4% 85,0% 85,9% 87,6% 74,6% 87,0% 85,5%

Czech Rep.


Slovenia ALL

P<0.0001S2 vs. S1 : P=0.001S3 vs. S2 : P=0.0002S3 vs. S1 : P<0.0001

Medication Use: Antiplatelets

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 85,2% 82,2% 82,1% 82,9% 72,0% 86,1% 77,5% 79,4% 80,8%

Survey 2 87,6% 81,9% 85,7% 86,3% 75,1% 91,5% 81,0% 82,3% 83,6%

Survey 3 92,5% 96,4% 98,1% 91,8% 86,1% 98,0% 95,7% 92,4% 93,2%

Czech Rep.


Slovenia ALL

P<0.0001

S2 vs. S1 : P=0.29S3 vs. S2 : P=0.0002S3 vs. S1 : P<0.0001

Medication Use: Statins

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 6,3% 34,9% 20,2% 31,1% 6,7% 6,8% 14,0% 23,2% 18,1%

Survey 2 38,8% 62,6% 61,0% 65,6% 45,2% 57,0% 75,1% 56,3% 57,3%

Survey 3 88,1% 95,2% 89,1% 85,4% 76,7% 90,0% 91,4% 90,1% 87,0%

Czech Rep. Finland France Germany Hungary ItalyNether-

landsSlovenia ALL

P<0.0001S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001

Prevalence of Raised LDL Cholesterol*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 95,4% 95,8% 96,8% 97,9% 97,0% 96,4%

Survey 2 87,8% 66,3% 78,7% 86,2% 73,0% 80,0% 64,5% 83,7% 78,1%

Survey 3 49,4% 26,4% 36,8% 54,2% 59,9% 56,4% 37,2% 44,5% 47,5%

Czech Rep.


Slovenia ALL

P<0.0001

S2 vs. S1 : P=0.001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001

•LDL C ≥ 2.5 mmol/L for patients fasting for at least 6 hours

Conclusioni dall’ EUROASPIRE surveys

I risultati relativi ai trends temporali di variazione dello stile di vita sonodecisamente sconfortanti: dimostrano come sia difficile per un adultocambiare abitudini di vita ma rispecchiano anche la limitatissima attenzione riservata dai medici alla prevenzione non farmacologica (GuyDe Baker, coordinatore nazionale per il Belgio di Euroaspire)

I pazienti hanno bisogno di un supporto professionale per modificare illoro stile di vita e per correggere i loro fattori di rischio in maniera piùefficace. Limitarsi a mettere loro in mano una ricetta non basta (DavidWood, principal investigator di Euroaspire)

Conclusions

• ‘A handful of pills is not enough’

Professor David A Woodon behalf of the EUROASPIRE Investigators

Obesity Trends* Among U.S. Adults: BRFSS, 1988

Mokdad A.H., CDC

(*BMI > 30, or ~ 30 lbs overweight for 5’4” woman)


Mokdad A.H., CDC

(*BMI > 30, or ~ 30 lbs overweight for 5’4” woman)(*BMI > 30, or ~ 30 lbs overweight for 5’4” oman)


Mokdad A.H., CDC

(*BMI > 30, or ~ 30 lbs overweight for 5’4” woman)

PatientPatientBMIBMI

PatientPatientBMIBMI

Obesity Management in an Outpatient Office Practice

37373737

29292929

3333333321212121

40404040 31313131 27272727 20202020

Source: Mokdad et al., Diabetes Care 2000;23:1278-83.

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS 1990

< 4%

4-6%

6-8%



Source: Mokdad et al., Diabetes Care 2000;23:1278-83.

< 4%

4-6%

6-8%



Source: Mokdad et al., J Am Med Assoc 2001;286:10.

< 4%

4-6%

6-8%

8-10%

> 10%

NHANES III Prevalence of Hypertension* According to BMI

14,9 15,2

22,1

27,727

32,7

41,937,8

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-<27 BMI 27-<30 BMI > 30

*Defined as mean systolic blood pressure 140 mm Hg, mean diastolic 90 mm Hg, or currently taking antihypertensive medication .

Brown C et al. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obes Res. 2000;8:605-619.

JACC 2008 52:979-985

The CRUSADE registry

Cumulative Incidence of Heart Failure According to Category of Body-Mass Index at the Base-Line Examination

Kenchaiah, S. et al. N Engl J Med 2002;347:305-313

- 15 - - - 20 - - - - 25 - - - - 30 - - - - 35 - - - - 40 - - - - 450

50

100

150

200

250

300

350

Relation of Body Mass Index to Mortality Ratio Body and Built Study, 1979

M o r t a l i t y

%

BMI

La pratica delle attività La pratica delle attività fisico-sportive oggifisico-sportive oggi

L’area totale dei cittadini attivi L’area totale dei cittadini attivi stimata dall’Istat-circa 36 stimata dall’Istat-circa 36 milioni nel 1999,si è ridotta nel milioni nel 1999,si è ridotta nel 2003 a circa 32 milioni e mezzo, 2003 a circa 32 milioni e mezzo, mentre l’area della sedentarietà mentre l’area della sedentarietà è salita da 19,5 a 23 milioni è salita da 19,5 a 23 milioni (sugli abitanti da 3 anni in su).(sugli abitanti da 3 anni in su).

AMSAMS

Weight Reduction

Energy Intake < Energy Expenditure

Dietary Therapy

Low-calorie diets (LCD) are recommended for weight loss in overweight and obese persons.Evidence Category A.

Reducing fat as part of an LCD is a practicalway to reduce calories. Evidence Category A.

Dietary Therapy

Low-calorie diets can reduce total body weight by an average of 8 percent and help reduce abdominal fat content over a period of 6 months. Evidence Category A.

Metabolic InfluenceMetabolic Influence

• Reduction of Reduction of obesityobesity

• Enhanced glucose Enhanced glucose tolerancetolerance

• Improved lipid Improved lipid profileprofile

Metabolic InfluenceMetabolic Influence

• Reduction of Reduction of obesityobesity

• Enhanced glucose Enhanced glucose tolerancetolerance

• Improved lipid Improved lipid profileprofile

Lifestyle InfluenceLifestyle Influence

• Decreaded likelihood Decreaded likelihood of smokingof smoking

• Possible reduction Possible reduction of stressof stress

• Short term reduction Short term reduction of appetiteof appetite

Lifestyle InfluenceLifestyle Influence

• Decreaded likelihood Decreaded likelihood of smokingof smoking

• Possible reduction Possible reduction of stressof stress

• Short term reduction Short term reduction of appetiteof appetite

Possible Biological Mechanisms for Possible Biological Mechanisms for Exercise-Induced Reductions in All-Causes Exercise-Induced Reductions in All-Causes

and Cardiac Mortalityand Cardiac Mortality

Increased physical activity with or without weigth Increased physical activity with or without weigth reduction,improves insulin action and reduces reduction,improves insulin action and reduces insulin resistance in obese persons. insulin resistance in obese persons. (evidence A)(evidence A)

Endurance exercise training when combined with Endurance exercise training when combined with weigth loss of > 4-5 Kg improves the lipid-weigth loss of > 4-5 Kg improves the lipid-lipoprotein profil by raising HDL cholesterol lipoprotein profil by raising HDL cholesterol and lowering trigliceridis among overweigth and lowering trigliceridis among overweigth and obese men and women. and obese men and women. (evidence A)(evidence A)

Dynamic aorobic physical activity with or without Dynamic aorobic physical activity with or without weigth loss,reduces blood pressure among weigth loss,reduces blood pressure among overweigth and obese with the greatest effect overweigth and obese with the greatest effect seen among persons with hypertension. seen among persons with hypertension. (evidence (evidence A)A)

Increased physical activity with or without weigth Increased physical activity with or without weigth reduction,improves insulin action and reduces reduction,improves insulin action and reduces insulin resistance in obese persons. insulin resistance in obese persons. (evidence A)(evidence A)

Endurance exercise training when combined with Endurance exercise training when combined with weigth loss of > 4-5 Kg improves the lipid-weigth loss of > 4-5 Kg improves the lipid-lipoprotein profil by raising HDL cholesterol lipoprotein profil by raising HDL cholesterol and lowering trigliceridis among overweigth and lowering trigliceridis among overweigth and obese men and women. and obese men and women. (evidence A)(evidence A)

Dynamic aorobic physical activity with or without Dynamic aorobic physical activity with or without weigth loss,reduces blood pressure among weigth loss,reduces blood pressure among overweigth and obese with the greatest effect overweigth and obese with the greatest effect seen among persons with hypertension. seen among persons with hypertension. (evidence (evidence A)A)

Exercise as Therapy: Evidence Based Sport Medicine D.MacAuley,T.B Best 2002

44

-10-10

-12-12

-16-16

-14-14

2200

-2-2-4-4-6-6-8-8

Systolic BPSystolic BPSystolic BPSystolic BP Diastolic BPDiastolic BPDiastolic BPDiastolic BP

All 48All 48comparisonscomparisons All 48All 48comparisonscomparisons

14 comparisons14 comparisons In hypertensivesIn hypertensives 14 comparisons14 comparisons In hypertensivesIn hypertensives

7 comparisons7 comparisons In Border LineIn Border Line hypertensiveshypertensives

7 comparisons7 comparisons In Border LineIn Border Line hypertensiveshypertensives

27 comparisons27 comparisons In normotensivesIn normotensives 27 comparisons27 comparisons In normotensivesIn normotensives

Net

BP

effe

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wi th

95%

con

f iden

ce i n

ter v

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mH

g)w

i t h 9

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onf i d

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i nt e

rval

( mm

Hg )

Net

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effe

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ent io

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Net

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J.Appl.Phys 1997J.Appl.Phys 1997

Reduction of resting blood Reduction of resting blood pressurepressure

Reduction of resting blood Reduction of resting blood pressurepressure

0

20

40

60

80

100

Relationship Between Physical Activity and Maintenance of Weight Loss

Not Maintained

Sub

ject

s E

xerc

isin

g (%

)

P<0.001

Kayman et al. Am J Clin Nutr 1990;52:800.

Weight Loss PatternMaintained

-25

-20

-15

-10

-5

0

Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body

Weight in Children 6-12 Years Old

0Time (months)

Decreased Sedentary Activity

Cha

nge

in P

erce

nt O

verw

eigh

t

Increased Physical Activity

Epstein et al. Health Psychol 1995;14:109.

4 8 12

Piramide dell’ attività fisica Piramide dell’ attività fisica Piramide dell’ attività fisica Piramide dell’ attività fisica

Incrementare l’ Incrementare l’ Esercizio fisico Esercizio fisico

quotidiano quotidiano

Ridurre il Ridurre il sedentarismo sedentarismo

Ridurre il Ridurre il sedentarismo sedentarismo

Promuovere l’ Promuovere l’ attività attività fisica fisica

Favorire la pratica

dello SPORT

ACSM/AHA 2007ACSM/AHA 2007RecommendationsRecommendations

Physical Activity and Public HealthPhysical Activity and Public Health

Circulation 2007;116-1081-1093 Circulation 2007;116-1081-1093

William L H, Russel R.P.William L H, Russel R.P.

..........

Moderate-Intensity Aerobic activity Moderate-Intensity Aerobic activity

for at least 30 min day for 5 days a weekfor at least 30 min day for 5 days a week

......Vigorous-intensity activity for 20 min ......Vigorous-intensity activity for 20 min three days each week three days each week

Risk factor % Cont % Cases OR (99% CI) adj for age, sex, smok

OR (99% CI) adj for all

ApoB/ApoA-1 (5 v 1) 20.0 33.5 3.87 (3.39, 4.42) 3.25 (2.81, 3.76)

Curr smoking 26.8 45.2 2.95 (2.72, 3.20) 2.87 (2.58, 3.19)

Diabetes 7.5 18.4 3.08 (2.77, 3.42) 2.37 (2.07, 2.71)

Hypertension 21.9 39.0 2.48 (2.30, 2.68) 1.91 (1.74, 2.10)

Abd Obesity 33.3 46.3 2.22 (2.03, 2.42) 1.62 (1.45, 1.80)

Psychosocial - - 2.51 (2.15, 2.93) 2.67 (2.21, 3.22)

Veg & fruits daily 42.4 35.8 0.70 (0.64, 0.77) 0.70 (0.62, 0.79)

Exercise 19.3 14.3 0.72 (0.65, 0.79) 0.86 (0.76, 0.97)

Alcohol Intake 24.5 24.0 0.79 (0.73, 0.86) 0.91 (0.82, 1.02)

All combined - - 129.2 (90.2, 185.0) 129.2(90.2, 185.0)

All combined (extremes) 333.7 (230.2, 483.9) 333.7 (230.2, 483.9)

INTERHEARTRisk of AMI associated with Risk Factors

in the Overall Population

INTERHEART

Risk of AMI with Multiple Risk Factors

Smk DM HTN APoB/A1+2+3 all4 +O +PS All RFs

2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7

1

2

4

8

16

32

64

128

256

512

OR

(99

% C

I)

DAGLI STILI DI VITA AI FARMACI ( O DAI FARMACI AGLI STILI DI VITA?) Dr. Brunello Cappelli.

Documents

mmhg slide

kgm slide

ppm slide

amsams slide

oman slide

weigth reduction

cardiac mortality slide

crusade registry slide