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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.