EUROACTION: Changes in diet and EUROACTION: Changes in diet and physical activity over one year in a family physical activity over one year in a family based preventive cardiology programme based preventive cardiology programme
in hospital and general practicein hospital and general practice
Jennifer Jones on behalf of the EUROACTION study group
Department of Cardiovascular Medicine, Imperial College, London, UK
The Multidisciplinary The Multidisciplinary family based family based EUROACTION EUROACTION ProgrammeProgramme
• In hospitals for coronary patients and their families
• In primary care for individuals at high risk of developing cardiovascular disease and their partners
EUROACTIONEUROACTION
Aim To raise the standards of preventive cardiology in Europe by demonstrating that the recommended European and
national lifestyle, risk factor and therapeutic goals in cardiovascular disease prevention are achievable and sustainable
in everyday clinical practice.
EUROACTION EUROACTION
Study design
A cluster randomised controlled trial in hospital and general practice with clinical follow-up at 16 weeks and 1
year
8 countries 24 centres 10,000+ subjects8 countries 24 centres 10,000+ subjects
EUROACTIONEUROACTION
Generalisable model of Generalisable model of preventive cardiology preventive cardiology
carecare
Nurse-led multidisciplinary Nurse-led multidisciplinary approachapproach
The EUROACTION team in Boldrini Hospital, Thiene, Italy The EUROACTION nurse and
the lead GP in Hoensbroek, The Netherlands
Identification and recruitment Identification and recruitment Multi-disciplinary initial Multi-disciplinary initial assessmentassessment
Preventive Cardiology ProgrammePreventive Cardiology Programme• Empowering families to change their lifestyle: smoking, Empowering families to change their lifestyle: smoking,
diet and physical activitydiet and physical activity• Blood pressure, blood cholesterol and blood glucose Blood pressure, blood cholesterol and blood glucose
managementmanagement• Compliance with cardio-protective medicationCompliance with cardio-protective medication• One to one and group approachOne to one and group approach• Supervised hospital and home exercise programmeSupervised hospital and home exercise programme• Health promotion workshop programmeHealth promotion workshop programme
16 week assessment 16 week assessment (hospital only)(hospital only)
One year follow-upOne year follow-up
Structure of the Programme in Structure of the Programme in Hospital and Primary CareHospital and Primary Care
Smoking cessation
IncreasingPhysical activity
Healthy eating,Weight
management
Lifestyle changeLifestyle change
• No smokingNo smoking• Saturated Fat: <10% total Saturated Fat: <10% total
EnergyEnergy• Fruits and vegetables: Fruits and vegetables:
>400g/day>400g/day• Fish: >20g/dayFish: >20g/day• Oily Fish: >3 times/weekOily Fish: >3 times/week• 30-45 minutes of physical 30-45 minutes of physical
activity at 60–75% of the activity at 60–75% of the average maximum heart average maximum heart rate on four-five days of rate on four-five days of the weekthe week
• Weight reduction ≥ 5%Weight reduction ≥ 5%• Waist <94 cm in men and Waist <94 cm in men and
<80 cm in women<80 cm in women
Aim of the dietary Aim of the dietary interventionintervention
To help patients and families to adopt a
diet associated with lowest risk of atherosclerotic disease
To help patients and families to achieve a healthy weight and shape
Dietary InterventionDietary Intervention
Individual Dietary Assessment of family habits
Anthropometric measures
Goal Setting
Education on Cardio-protective diet
Individualised and group advice
Regular monitoring and follow up
If weight loss identified If weight loss identified as priorityas priority
Measuring height and weight European Recommendations• BMI:
• <25kg/m2 • Waist:
• Women <80cm; Men <94cm• Target weights set
• 5-10% weight loss
• Behaviour strategies• Weekly weigh ins• Portion sizes• Food diaries
Physical ActivityPhysical Activity
Individual Physical Activity Assessment 7 day activity recall Pedometer Functional capacity Functional limitation Activity perceptions, barriers and motivators
Goal Setting
Education on Benefits of Physical Activity
Thiene, Italy
Valencia, Spain
The Supervised Exercise The Supervised Exercise Programme in HospitalProgramme in Hospital
Non-equipment based weekly Non-equipment based weekly supervised programmesupervised programme
Tailored physical activity adviceTailored physical activity advice MonitoredMonitored ProgressiveProgressive
Identification of local facilitiesIdentification of local facilities Philosophy of empowermentPhilosophy of empowerment
Physical Activity Advice Physical Activity Advice in Primary Carein Primary Care
Facilities Specialist schemes Experts Activities available
Educational MaterialsEducational Materials
Goal setting and Goal setting and tracking progress tracking progress with the with the Personal Personal
Record CardRecord Card
RESULTS
17%
35%48%
AMI
UA
SA
Index Event: Coronary PatientsIndex Event: Coronary Patients
69.9 % Male 69.9 % Male
Mean age overall 62.5 yearsMean age overall 62.5 years
26%
32%42%
SCORE
BP &LipidsDiabetes
High Risk PatientsHigh Risk Patients
49.8 % Male 49.8 % Male
Mean age overall 62.0 yearsMean age overall 62.0 years
One year One year assessmentassessment
Identification Identification
Participation Participation in the in the
ProgrammeProgramme
InterventionIntervention
PATIENTSPATIENTS
946 (89%)946 (89%)****
Hospital ArmHospital Arm
Initial Initial assessment assessment
3073071061 (67%)1061 (67%)**
16941694 828828
646646
401401
17181718
994994
802802
335335
PARTNERSPARTNERS PATIENTSPATIENTS PARTNERSPARTNERS
Usual CareUsual Care
860 (82%)860 (82%)**** 410410
*Of those eligible **Of those who attended initial assessment*Of those eligible **Of those who attended initial assessment
One year One year assessmentassessment
Identification Identification
Participation Participation in the in the
ProgrammeProgramme
InterventionIntervention
PATIENTSPATIENTS
1019 (91%)1019 (91%)****
Primary Care ArmPrimary Care Arm
Initial Initial assessment assessment
3313311118 (89%)1118 (89%)**
12571257 805805
261261
225225
17521752
10051005
830830
NANA
363363
PARTNERSPARTNERS PATIENTSPATIENTS PARTNERSPARTNERS
Usual CareUsual Care
947 (85%)947 (85%)**** 204204
*Of those eligible **Of those who attended initial assessment*Of those eligible **Of those who attended initial assessment
Change in proportion of patients achieving Change in proportion of patients achieving the European targets for a healthy diet from the European targets for a healthy diet from
initial assessment to 1 yearinitial assessment to 1 year
Coronary PatientsCoronary Patients High Risk PatientsHigh Risk Patients
6
20
27
4440
5
10
15
20
25
30
Fruits andvegetables >400
g/ day
Fish > 20 g/ day Oily fish > 3times/ week
+23.6% +23.6% (9.1 to 38.2)*(9.1 to 38.2)*
+16.5% +16.5% (-0.1 to 33.1)(-0.1 to 33.1)
+15.8% +15.8% (2.2 to 29.3)*(2.2 to 29.3)*
+11.8%+11.8% (-2.1 to (-2.1 to
25.6)25.6) +11.4%+11.4% (0.6 to (0.6 to 22.1)*22.1)*
+2.2% +2.2% (-1.7 to (-1.7 to
6.2)6.2)
14
2425
3
109
0
5
10
15
20
25
30
Fruits andvegetables >400
g/ day
Fish > 20 g/ day Oily fish > 3times/ week
Intervention Intervention Usual Care Usual Care **p<0.05p<0.05
0.2
27
0
5
10
15
20
25
30
24
-10
-15
-10
-5
0
5
10
15
20
25
30
High Risk PatientsHigh Risk Patients
+ 32.9% (1.8 to 53.9)*+ 32.9% (1.8 to 53.9)*
Coronary PatientsCoronary Patients
+ 28.1% (13.9 to + 42.3)*+ 28.1% (13.9 to + 42.3)*
Change in proportion of patients participating in Change in proportion of patients participating in moderate intensity activity ≥4 times/week moderate intensity activity ≥4 times/week
≥30minutes from initial assessment to 1 year≥30minutes from initial assessment to 1 year
Intervention Intervention Usual Care Usual Care **p<0.05p<0.05
-0.5
0.1
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
HighHigh RiskRisk PatientsPatientsCoronaryCoronary PatientsPatients
Mean change in BMI in those ≥25kg/m² and from Mean change in BMI in those ≥25kg/m² and from initial assessment to 1 year**initial assessment to 1 year**
-0.3
0.4
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
0.4
0.5
-0.69 kg/m² (-1.03 to --0.69 kg/m² (-1.03 to -0.34)* 0.34)* -2.8 kg/m² (-13.1 to +7.5)-2.8 kg/m² (-13.1 to +7.5)
Intervention Intervention Usual Care Usual Care **p<0.05 **random subsample in usual carep<0.05 **random subsample in usual care
-0.21
-1.66
-1.8
-1.6
-1.4
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
High Risk PatientsHigh Risk PatientsCoronary PatientsCoronary Patients
Mean change in waist circumference in menMean change in waist circumference in men ≥94cm and women ≥80cm from initial ≥94cm and women ≥80cm from initial
assessment to 1 year**assessment to 1 year**
-1.5
-0.8
-1.6
-1.4
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
-0.8 cm (-3.7 to -0.8 cm (-3.7 to 2.1) 2.1)
-1.61 cm (-2.61 to --1.61 cm (-2.61 to -0.61)*0.61)*
Intervention Intervention Usual Care Usual Care **p<0.05 **random subsample in usual carep<0.05 **random subsample in usual care
40
2931
57
2622
0
10
20
30
40
50
60
Ideal Level 1 Level 2
%
51
2523
54
27
15
0
10
20
30
40
50
60
Ideal Level 1 Level 2
%
**OR 0.70 (0.53 to 0.93), OR 0.70 (0.53 to 0.93), p=0.02p=0.02
General General PracticePractice
Hospital Hospital
Distribution of Waist Distribution of Waist Circumference at One year – All Circumference at One year – All
PatientsPatients
**OR 0.61 (0.39 to 0.97), OR 0.61 (0.39 to 0.97), p=0.04p=0.04
*Proportional odds model*Proportional odds model
ConclusionsConclusions
The nurse-led multidisciplinarynurse-led multidisciplinary EUROACTION familyfamily based programme achieved significantly better lifestyle lifestyle changeschanges for coronary and high risk
patients in terms of a more healthy diethealthy diet, reduction in abdominal obesity and
increased physical activityphysical activity compared to usual care.
ConclusionsConclusions
EUROACTION has set
new standards of preventive cardiology new standards of preventive cardiology care care
for coronary and high risk patients and their families in everyday clinical practice
EUROACTIONEUROACTIONA European Society of Cardiology
demonstration project in preventive cardiology
www.escardio.org/euroaction
solely sponsored by an unconditional educational grant from Astra Zeneca