DAGLI STILI DI VITA AI FARMACI ( O DAI FARMACI AGLI STILI DI VITA?) Dr. Brunello Cappelli.
Transcript of 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.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.0006
S2 vs. S1 : P=0.009S3 vs. S2 : P=0.051S3 vs. S1 : P=0.0002
* 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.
Finland France Germany Hungary ItalyNether-lands
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.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.004
S2 vs. S1 : P=0.21S3 vs. S2 : P=0.02S3 vs. S1 : P=0.001
* 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.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.04
S2 vs. S1 : P=0.82S3 vs. S2 : P=0.03S3 vs. S1 : P=0.08
* 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.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.64
S2 vs. S1 : P=0.83S3 vs. S2 : P=0.37S3 vs. S1 : P=0.48
* 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
S2 vs. S1 : P=0.83S3 vs. S2 : P=0.51S3 vs. S1 : P=0.65
* 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.
Finland France Germany Hungary ItalyNether-lands
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.
Finland France Germany Hungary ItalyNether-lands
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.
Finland France Germany Hungary ItalyNether-lands
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)
Obesity Trends* Among U.S. Adults: BRFSS, 1994
Mokdad A.H., CDC
(*BMI > 30, or ~ 30 lbs overweight for 5’4” woman)(*BMI > 30, or ~ 30 lbs overweight for 5’4” oman)
Obesity Trends* Among U.S. Adults: BRFSS, 2000
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%
Diabetes Trends* Among Adults in the U.S.,
(Includes Gestational Diabetes) BRFSS 1995
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
< 4%
4-6%
6-8%
Diabetes Trends* Among Adults in the U.S.,
(Includes Gestational Diabetes) BRFSS 2001
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
ct i
n i n
ter v
ent io
n co
mpa
red
t o
con t
r ol
Net
BP
eff e
ct i
n i n
t erv
ent i o
n co
mpa
r ed
t o
cont
r ol
wi th
95%
con
f iden
ce i n
ter v
al ( m
mH
g)w
i t h 9
5% c
onf i d
ence
i nt e
rval
( mm
Hg )
Net
BP
effe
ct i
n i n
ter v
ent io
n co
mpa
red
t o
con t
r ol
Net
BP
eff e
ct i
n i n
t erv
ent i o
n co
mpa
r ed
t o
cont
r ol
wi th
95%
con
f iden
ce i n
ter v
al ( m
mH
g)w
i t h 9
5% c
onf i d
ence
i nt e
rval
( mm
Hg )
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)