Nutrition –Health Alliance‘NUTRIHEAL’

Meditterranean-type Nutrition Intervention Program

for patients with Cardiometabolic Diseases

Maria HassapidouProfessor of Nutrition and Dietetics,ATEITH,Thessaloniki,Greece

Fi Financed by NSRF Reference Framework (NSRF) 2007 -2013ΝNNational Strategic Reference Framework (NSRF) 2007 -2013National Strategic Reference Framework (NSRF) 2National Strategic

Reference Framework (NSRF) 2007 -2013007 -2013

National Strategic Reference Framework (NSRF) 2007 -2013

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The rapid increase of cardiometabolic diseases (obesity, type II diabetes, dyslipidemia, hypertension, cardiovascular diseases)in Greece,the last decades leading to increased morbidity and mortality and the related health care costs made a necessity the development and implementation of intervention strategies targeted to the needs of specific population groups.

Recent data show that one third of Greeks are obese, 10% suffer from diabetes and one third has hypertension. Greece has still an upward trend for cardiovascular morbidity and mortality, in contrast to most European countries where it has been stabilized or is decreasing and this is mainly due to the abandonment of the traditional way of eating and living. From the few data available for our country, cardiovascular diseases represent 10% of total health care costs, which is equivalent to 1,922,000 euros annually. Indirect economic costs include the cost of lost productivity due to morbidity and premature mortality.

The abandonment of the Mediterranean diet and the adoption of Western dietary model, i.e. food that is high in calories ,saturated and trans fats, salt and sugars and low in fiber and antioxidants is the major factor for the rapid increase of cardiometabolic diseases in Greece.

Paletas K. et al.,Jour of the American College of Nutrition.2010;29(1):41-45

Trichopoulou A et al.,Arch Intern Med. 2005;165 (8): 929-935

The combination of diet and physical activity may reduce cardiovascular risk by about 82%, while a healthy diet alone by 60%. Specifically, regarding the risk factors, proper healthy diet can reduce body weight by about 10 % or more -depending on the case-, blood pressure by 10 mmHg, LDL cholesterol by 20% and in combination with behavior modification can reduce the risk of type 2 diabetes by 58%.

Bertsias G et al et al.,BMC Public Health. 2003,3:3

Kapantais E et al. Ann Nutr Metab. 2006;50:330-338

Roditis M et al., Jour of Pediatric Endoc and Matab, 2009,22,389-405

The importance of the Mediterranean diet in the prevention and treatment of cardiometabolic diseases has been well documented in a number of studies.

Esruch et al,2006Vincent-Baudry et al., 2005Esposito et al., 2004Michalsen et al., 2006Toobert et al., 2003

Esruch et al,2006Vincent-Baudry et al., 2005Esposito et al., 2004Michalsen et al., 2006Toobert et al., 2003

Body weight reduction

Table 1 . Summary of lifestyle intervention to prevent diabetes and reduce CVD risk (Horton,2009)

Author Study (country)

Population(age, BMI)

Condition

DurationFollow-up

Intervention Relative risk reduction T2DM vs. controls

Pan et al.,1997

Da Qing Study (China)

577 (45 years, 25.6 kg/m2)

IGT 6 years EX onlyEX + DIETDIET only

47%38%33%

Tuomilehto et al., 2001

Diabetes PreventionStudy (Finland)

522 (55 years, 31.0kg/m2)

IGT 3.2 years EX + DIET 58%

Knowler et al., 2002

Diabetes PreventionProgram (USA)

3234 (51 years, 34.0kg/m2)

IGT 2.8 years EX + DIETMetformin

58%31%

Bray et al., 2006

Look Ahead Trial (USA)

5145 (59 years, 36kg/m2)

T2DM 1 year (until today)

EX + DIET N/A

: ΕΧ Exercise DIET: Dietary Treatment

Table 1 . Summary of lifestyle intervention to prevent diabetes and reduce CVD risk (Horton,2009)

Author Study (country)

Population(age, BMI)

Condition

DurationFollow-up

Intervention Relative risk reduction T2DM vs. controls

Pan et al.,1997

Da Qing Study (China)

577 (45 years, 25.6 kg/m2)

IGT 6 years EX onlyEX + DIETDIET only

47%38%33%

Tuomilehto et al., 2001

Diabetes PreventionStudy (Finland)

522 (55 years, 31.0kg/m2)

IGT 3.2 years EX + DIET 58%

Knowler et al., 2002

Diabetes PreventionProgram (USA)

3234 (51 years, 34.0kg/m2)

IGT 2.8 years EX + DIETMetformin

58%31%

Bray et al., 2006

Look Ahead Trial (USA)

5145 (59 years, 36kg/m2)

T2DM 1 year (until today)

EX + DIET N/A

: ΕΧ Exercise DIET: Dietary Treatment

Given the lack of national programs targeted in nutrition education for adults and elders in Greece, the proposed project “Nutriheal” includes targeted actions for adults and elders with cardiometabolic diseases, which are based on tested interventions internationally. The program is expected to improve health and quality of life of the diseased, as well as the healthy (at the level of prevention) population. The expected impact is summarized in reducing morbidity and associated health care costs of people by improving their diet.

ObjectiveObjective of the Project of the Project

ObjectivesObjectives of the of the ProjectProject

Nutritional Education Intervention Program

Nutriheal

reduction of cardiometabolic diseases

Improvement of level of health

reduction in direct and indirect economic costs

reduction of lost productivity

The intervention program is carried out by Greek dietitians. Fifteen dietitians are participating in the program. Each dietitian is responsible for three municipalities.

Methodology

. r 6 months. The intervention group (I) received a M All

Subjects were randomized into 2 groups and followed for 6 months. The intervention group (I) received a Mediterranean-type healthy diet personalized in calories and nutrients according to the patient’s diseases, and followed monthly by a dietitian, and the control group (C) did not receive any dietary counseling.ng

Methodology

Measurements : BMI %Body Fat (%BF) by BIA waist circumference(W)serum lipids (TC,TG,LDL-C,HDL-C) Fasting plasma glucose (FPG)HBA1c (only in diabetic patients)Systolic (SBP) and Diastolic (DBP) blood pressure

Methodology

Deliverables:Literature review with detailed and evidenced

based methodology.Electronic file with the organizational chart of

the interventionInformation/Education material.

Workpackage 1: Design and Implementation of Intervention Programs

Work Package 1.1: Literature review & design of intervention programs

Diet and Obesity

Principles of Healthy Nutrition

NUTRITION AND HYPERLIPIDEMIA NUTRITION AND

CARDIOVASCULAR DISEASE

Nutrition and DiabetesNutrition and

Hypertention

Work Package 1.2: Raising awareness of health professionals

regarding nutrition and healthy lifestyle

There will be 5 seminars in each municipality of awareness for health professionals (doctors, nurses, physiotherapists, social workers, sports scientists) about nutrition and healthy lifestyles.

One seminar will be organised in each municipality for the general public about the role of nutrition in prevention and treatment of cardiometabolic diseases and the way to help patients to change their nutritional behaviour.

Intervention programs are implemented in 50 municipalities in Greece selected by random sampling. The intervention is taking place in groups according to age (25-44, 45-65 and over 65 years)and disease (Obesity, type II diabetes,hyperlipidemia, hypertension, and cardiovascular disease) with ten meetings-interventions in each age group.

Intervention is carried out by dietitians and diet treatment is based on the Mediterranean diet model and personalised according to age, sex, disease and dietary needs.

Work Package 1.3: Intervention programs in Municipalities for patients

with cardiometabolic diseases.

Deliverables:-Intervention programs in municipalities (50 in total) in

three age groups (a total of 90 persons per municipality, 60 adults and 30 elders) for five cardiometabolic diseases (obesity, type II diabetes, dyslipidemia, hypertension, cardiovascular disease). Each intervention includes individualized counseling in at least 5 meetings. Therefore 5x50x90 = 22500 total sessions will be implemented (30 min each).

-Database of dietitians, doctors university professors, scientific societies, hospital departments & clinics that are related to the treatment of cardiometabolic diseases as well as links of municipalities, associations of patients (e.g. diabetics) and other relevant bodies.

Work Package 1.3: Intervention programs in Municipalities for patients

with degenerative diseases.

Workpackage 2 aims to the promotion of intervention activities that include:

Production of radio spots, with emphasis on radio repeated messages at local level to increase the involvement both of health professionals in the awareness seminars, and of the general public and the patients in the intervention programs.

Publications in local electronic and printed media, magazines and daily newspapers.

Dissemination of results (publications, presentations in special conferences, seminars and scientific events)

Web siteSocial media

Workpackage 2: Dissemination and promotion of the project activities

Base line characteristics of the participantsMen (n = 693) Women (n=2525)

Age (yrs) 56.3415.47 54.6713.77

Body Weight (Kg) 97.6919.73**a 84.4417.38**a

Body Height (m) 1.740.07**b 1.600.007**b

Body Fat (%) 32.678.20**c 41.907.21**c

BMI 32.325.89*d 32.846.55*d

Waist circumference (cm) 11113**e 10314**e

Hip circumference (cm) 11010**f 11313**f

WHR 1.010.09**g 0.910.10**g

Neck circumference (cm) 424**h 363**h

* p<0.05 **p<0.001

*p<0.05

**p<0.001 **p<0.001

**p<0.001

Total Diseases

54,4%

17,8%50%

12,50%

41,1%

Coronary Disease (%) Hypertension (%) Hyperlipidemia (%)

Diabetes (%) Overweight - Obesity (%)

20,3 10,30

46,6 39,50

47,9 50,60

29,1 14,7

35,8 59,4

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Coronary Disease (%)

Hypertension (%)

Hyperlipidaimia (%)

Diabetes (%)

Overweight-Obesity (%)

Men (n = 693) Women (n=2525)

Total Diseases Men and Women

Walking Assessment (Men)Walking≥ 210min/week Walking <210min/week

Age (yrs) 58.5914.02*a 55.4115.95*a

Body Weight (Kg) 93,4416.70**b 99.4620.62**b

Body Height (m) 1.730.07 1.740.07

Body Fat (%) 31.827.66 33.028.40

BMI 31.104.73**c 32.826.24**c

Waist circumference (cm)

10813*d 11213*d

Hip circumference (cm) 1089**e 11110**e

WHR 1.000.08 1.000.09

Neck circumference (cm)

413 424

*p<0.05 **p<0.001

Biochemical measurements and exercise (Men)

Walking≥ 210min/week Walking <210min/week

Total cholesterol (mg/dL)

19641 19938

LDL cholesterol (mg/dL)

12438 12233

HDL cholesterol (mg/dL)

4713**f 5016**f

Triglycerides (mg/dL) 14070 13959

Glucose (mg/dL) 11444 11233

Glycosylated (mg/dL) 6.833.11 6.622.10

Systolic blood pressure 12914 13116

Diastolic blood pressure

8312 8211

Sitting (hours/week) 38.5520.89*g 43.3029.24*g

*p<0.05 **p<0.001

Total Men

18,9

23,945,8

48,8

47,3

49,3

28,3

31,3

36,7

33,3

0

10

20

30

40

50

60

70

80

90

100

CoronaryDisease (%)

Hypertension (%) Dyslipidaimia(%)

Diabetes (%) Dieting (%)

Walking≥ 210min/week Walking < 210min/week

In the total sample (n = 3218):In men walking was negatively associated with hip

circumference (-,088, p<0.05).In women walking was associated with body weight (-,062, p<0.05), BMI (-,046, p<0.05), waist circumference (-,063, p<0.001), WHR (-,062, p<0.001), neck circumference (-,049, p<0.05) and triglycerides (-,069, p<0.001).

In the total sample (n = 3218): Walking presented statistical significant

negative correlation with BMI (-,047, p<0.001), waist circumference (-,036, p<0.001), hip circumference (-,040, p<0.05) and triglycerides (-,058, p<0.001).

Assessment of interventionIntervention before(N229)

Intervention after(N229)

Controlbefore(N122)

Controlafter(122)

Body Weight (Kg)

88.8017.18**a

84.4417.38**a

88.8119.09 89.5820.64

Body Fat (%) 40.237.73 40.068.05 38.157.69 38.517.77

BMI 34.296.01**b 33.585.88**b 32.345.91 32.596.18

Waist circumference (cm)

10514**c 10314**c 10616 10615

Hip circumference (cm)

11512**d 11311**d 11513 11412

WHR 0.910.10 0.910.10 0.920.11 0.930.11

Neck circumference (cm)

373 373 384 394

*p<0.05 **p<0.001

Assessment of intervention Intervention before(N229)

Intervention after(N229)

ControlBefore(N122)

Controlafter(N122)

Total chol (mg/dL)

20641**e 19534**e 20444**a 21145**a

LDL chol (mg/dL)

12834**f 11931**f 12838 13237

HDL chol (mg/dL)

5415 5514 4914 4812

Triglycerides (mg/dL)

13458*j 12449*j 14259 14785

Glucose (mg/dL)

10925**k 10522**k 10429 10522

Systolic blood pressure

12611 12511 12611 12531

Diastolic blood pressure

819 819 8210 829

*p<0.05 **p<0.001

Body Weight Change

88,8kg84,44kg

88,81kg 89,58kg

0

10

20

30

40

50

60

70

80

90

100

baseline after 6 months

intervention n 229 control n122

BMI Change

34,29 33,5832,34 32,59

0

5

10

15

20

25

30

35

40

baseline after 6 months

intervention n 229 control n122

Waist and Hip circumference changes

105cm

103cm

106cm 106cm

101,5

102

102,5

103

103,5

104

104,5

105

105,5

106

106,5

baseline after 6 months

intervention n 229 control n122

Waist

115cm

113cm

115cm

114cm

112

112,5

113

113,5

114

114,5

115

115,5

baseline after 6 months

intervention n 229 control n122

Hip

Total Cholesterol

206mg/dL

204mg/dL

195mg/dL

211mg/dL

185

190

195

200

205

210

215

baseline after 6 months

intervention n 229 control n122

128mg/dL 128mg/dL

119mg/dL

132mg/dL

112

114

116

118

120

122

124

126

128

130

132

baseline after 6 months

intervention n 229 control n122

LDL Cholesterol

Triglycerides

134mg/dL

142mg/dL

124mg/dL

147mg/dL

110

115

120

125

130

135

140

145

150

baseline after 6 months

intervention n 229 control n122

109mg/dL 104mg/dL 105mg/dL105mg/dL

0

20

40

60

80

100

120

baseline after 6 months

intervention n 229 control n122

Glucose

Conclusion In conclusion, preliminary data from this

nutrition intervention study in Greek municipalities carried out by dietitians suggest that a well balanced Mediterranean-type diet is able to reduce several metabolic risk factors in patients with CM diseases.

It also showed the essential role of dietitans in communities in health prevention and in dietary intervention programs.