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+ subjectsEUROACTIONEUROACTION

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 MaterialsGoal setting and Goal setting and tracking progress tracking progress with the with the Personal Personal

Record CardRecord Card

RESULTS

17%

35%48%

AMI

UASA

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

44405

1015202530

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

05

1015202530

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

-15-10-505

1015202530

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

00.10.2

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

00.10.20.30.40.5

-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