Prevention: The Ferrara Example
Transcript of Prevention: The Ferrara Example
Prevention:
The Ferrara Example
Roberto Ferrari
Introduction
• In the last 30 years, life span has increased by 8 years
• Cardiology has contributed to at least 6 of these years
• CV death continues to be the number 1 killer worldwide
Introduction
• We have only delayed CV death and transformed an acute disease into a chronic one
• We should not drop our guard - and we will not
•We are trained to treat
•We have proven that we are able to do so
•Only recently we pay attention to prevention
Treatment vs Prevention
• Role of therapy (Asprin, ACE-inhibitors, statins, β-blockers) is enormous.
• The more costly interventions (although highly advocated by cardiologists) contribute little.
Treatment vs Prevention
• Revascularisation explains 5% of the fall in CV death.
• It is applied too late or to toofew and is too expensive
• Even doubling revascularisation would make little difference
Treatment vs Prevention
•Treatment accounts for between 25-55% of the CV mortality decline
•Prevention accounts for between 45-75%
Prevention vs Treatment
•Treatment rests in the hands of cardiologists
•Prevention does not and should not
Prevention vs Treatment
Which prevention strategy?
1 - A population strategy
•Paramount importance
•Dealt with by doctors, institutions, cities, nations, policy makers, politicians
2 - High risk strategy
• Important for a minority of asymptomatic individuals
• Dealt with by GPs and cardiologists
Which prevention strategy?
3 - Secondary prevention
• Important but limited for survivors
•Dealt with by cardiologists
Which prevention strategy?
What is prevention?
• Awareness, behavior, laws, education, lifestyle, etc.
• Alteration of majority (if not all) aspects of the Western civilisation.
• Too important to be left to medical doctors alone.
What is prevention?
•More than a list of do’s and don’ts
•More than forbidden pleasures or imposed burdens
Prevention and lifestyle
•Changing the lifestyle of a population for the better is not an easy task
• Ironically it is easier to deteriorate it
Changing lifestyle
• A battle against the negative subliminal messages from consumer society (movies, TV, internet).
• A challenge to important economic interests.
Walking the dog
Ferraraa city of
prevention
Why Ferrara?
• A city of 131.000 inhabitants
• With more than 600 years of university culture
• With close links between different institutions
Why Ferrara?
• 9 Km of medieval wall
Why Ferrara?
• 9 Km of medieval wall
• A city of bicycles
Why Ferrara?
• 9 Km of medieval wall
• A city of bicycles
• Number 1 producer of fruit and vegetables in Italy
Why Ferrara?
• 9 Km of medieval wall
• A city of bicycles
• Number 1 producer of fruit and vegetables in Italy
• Heavy fishing industry
Why Ferrara?
• 9 Km of medieval wall
• A city of bicycles
• Number 1 producer of fruit and vegetables in Italy
• Heavy fishing industry
• Only 1 cardiological department!
An integrated project with the:
• Italian Ministry of Health
• Italian National Institute of Health
• University and Hospital of Ferrara
• Regional Health Government
• Ferrara Municipality and District Councils
Ferrara: City of Prevention
An integrated project with the:
• GVM Hospitals of Care and
Research
• Anna Maria Sechi Foundation
• Various patient associations
• Hospitality and catering industry
• Fruit and vegetable industry
• Fishing industry
Ferrara: City of Prevention
An integrated project of:
• Surveillance of disease burden
• Preventative action at population
and individual levels
• Assessment of the efficacy
Ferrara: City of Prevention
Surveillance: determination of risk
chart of different populations:
• Cultured “Arte e Prevenzione”
• Specialised Ferrara Hospital
• Daily life Supermarkets
• Workers Mechanic industry
Ferrara: City of Prevention
We calculated the risk chart
of visitors to the first
exhibition of the Hermitage
Foundation on “Garofalo”
at the Estense Castle.
Benvenuto Tisi detto il Garofalo
Le Nozze di Cana di Galilea, 1531
Olio su tela, cm 306x248
San Pietroburgo, Museo Statale
Ermitage
Benvenuto Tisi detto il Garofalo
Allegoria di Ercole d’Este e di
Ferrara, 1534
Olio su tela, cm 86x116
Vienna, Liechtenstein Museum
Two risk charts:
• The Italian Ministry of Health
• Ours, enriched by BMI, abdominal circumference, HR, anamstetic and educational data
• Determined by cardiologist, audited by Italian National Institute of Health
•The experience will be
repeated yearly.
•100 individuals at very low
and very high risk will have
regular CV check-ups.
Objectives
•Determine the prevalence of cardiovascular risk factors in a population of motivated subjects attending the “Garofalo” exhibition.
•4208 medical records
Outcome
Measures
How many – likely low-risk
individuals – are on target for CV
disease prevention as per:
• Italian National Institute of Health
• 2007 Joint ESC Guidelines on
CVD Prevention
73% 73% 73%
0%
20%
40%
60%
80%
100%
N=3072
ALL MEN WOMEN
N=1405 N=1677
% with high level of education
17% 18% 16%
0%
20%
40%
60%
80%
100%
N=704
ALL MEN WOMEN
N=340 N=364
% of smokers
Prevalence of
diabetes, elevated
blood pressure
and lipids.
3% 3% 2%
0%
20%
40%
60%
80%
100%
N=144
ALL MEN WOMEN
N=56 N=48
% of diabetes
56%50%
61%
0%
20%
40%
60%
80%
100%
N=2370
ALL MEN WOMEN
N=973 N=1397
% of Heart Rate > 70 bpm
Even in the low-risk population studied
• hypertension
• overweight
• sedentary
• optimal HR
are not at target – they are a lifestyle problem
Therefore
Ferrara: City of Prevention
Preventative action
University
and
GVM
FASC
Foundation,
School of
Prevention
Food
Industry
National
TV
Frozen
Products
Industry
University
and
GVM
FASC
Foundation,
School of
Prevention
Food
Industry
Dedicated
Health
Channel
Frozen
Products
Industry
Ferrara: City of Prevention
Preventative action
University
and
GVM
FASC
Foundation,
School of
Prevention
Production
of adequate
food
Dedicated
Health
Channel
Frozen
Products
Industry
Ferrara: City of Prevention
Preventative action
University
and
GVM
FASC
Foundation,
School of
Prevention
Production
of adequate
food
Dedicated
Health
Channel
Frozen
adequate
menus
Ferrara: City of Prevention
Preventative action
University
and
GVM
Awareness
Website
Professionals
Books
Production
of adequate
food
Dedicated
Health
Channel
Frozen
adequate
menus
Ferrara: City of Prevention
Preventative action
Preventative individual action
• Creation of “home of prevention”
strategically located – Palazzo
Turchi di Bagni in front of the
Palazzo dei Diamanti in the heart
of the city
Ferrara: City of Prevention
Ferrara: Home of prevention – what is it?
•A place where citizens
can assess their
individual cardiovascular
risk whenever they want.
Ferrara: Home of prevention – what is it?
• A place where ad hoc trained
personnel (from the school)
dedicate time to citizens to
help them remain healthy and
to provide suggestions to
high risk patients.
Ferrara: The home of prevention – what is it?
• A place to learn how to:
stop smoking
shop for appropriate ingredients
prepare appropriate menus
exercise
Ferrara: The home of prevention – what is it?
•A place with an operative
kitchen for proper cookery
courses.
•A place where educational
material can be found.
• Website: “Cuore al Centro”
• TV: 1 hour daily education at a national level.
• Constitution of a university certified digital health channel
Ferrara: City of Prevention Global preventative action
•Preparation of frozen portions of adequate food
•Production of heart healthy bread and cakes
•Preparation of adequate frozen menus for hospitals
Ferrara: City of Prevention Global preventative action
White, no salt, high omega3, fibres and… tasty!
•The concept will be exported to ten cities where GVM is operating.
•Data will be horizontally collected yearly for at least 10 years and compared with the general population.
Ferrara: City of Prevention Project assessment
• This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning…
• We hope in 10 years to:
understand how and why people make the wrong decision regarding diet and lifestyle
convince a city to have the courage to advocate policy changes for the better
produce a model for CV prevention
Conclusion
Conclusion
Roberto Ferrari
25% 23%26%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
N=1037
17%18% 16%
ALL MEN WOMEN
N=450 N=587
% of sedentary
METTERE INSIEME A ADDOMINAL OBESIY
46%
36%
55%
0%
20%
40%
60%
80%
100%
N=1948
18% 16%
ALL MEN WOMEN
N=689 N=1259
% of abdominal obesity(Waist circumference > 102 cm in Men and > 88 cm in Women)
49%
37%
58%
0%
20%
40%
60%
80%
100%
N=2051
BMI < 25
ALL MEN WOMEN
N=722 N=1329
% with BMI < 25
METTERE INSIEME i 3 BMI
35%
45%
26%
0%
20%
40%
60%
80%
100%
N=1475
25 < BMI < 30
ALL MEN WOMEN
N=881 N=594
% with 25 < BMI < 30
12% 12% 12%
0%
20%
40%
60%
80%
100%
N=489
BMI > 30
ALL MEN WOMEN
N=236 N=253
% with BMI > 30
60%
51%
67%
0%
20%
40%
60%
80%
100%
N=2505
% with DBP < 90 mmHg AND
SBP < 140 mmHg
ALL MEN WOMEN
N=987 N=1518
6% 9%4%
0%
20%
40%
60%
80%
100%
N=267
90 < DBP < 95 mmHg AND
140 < SBP < 160 mmHg
ALL MEN WOMEN
N=181 N=86
% with 90 < DBP < 95 mmHg
and 140 < SBP < 160 mmHg
4% 5% 3%
0%
20%
40%
60%
80%
100%
N=152
DBP > 95 mmHg AND
SBP > 160 mmHg
ALL MEN WOMEN
N=100 N=52
% with DBP > 95 mmHg
and SBP > 160 mmHg
61%
69%
55%
0%
20%
40%
60%
80%
100%
N=2582
Total Cholesterol < 200 mg/dl
ALL MEN WOMEN
N=1331 N=1251
% with Total Cholesterol < 200 mg/dl
27%22%
30%
0%
20%
40%
60%
80%
100%
N=1099
200 < Total Cholesterol < 240
mg/dl
ALL MEN WOMEN
N=422 N=677
% with 200 < Tot Cholesterol < 240 mg/dl
12%9%
13%
0%
20%
40%
60%
80%
100%
N=435
Total Cholesterol ≥ 240
mg/dl
ALL MEN WOMEN
N=141 N=294
% with total cholesterol ≥ 240 mg/dl
CARTA DEL RISCHIO
ISTITUTO SUPERIORE DI SANITA’
3346 SUBJECTS, AGE 40 - 69
12%
28%
22%
5%
0%
4%
10%
4%
0% 0%
5%4%
0% 0%
2%1%
0% 0%1% 1%
0%
5%
10%
15%
20%
25%
30%
40-44 45-54 55-64 65-69
Years
risk <5% risk 5-10% risk 10-15%
risk 15-20% risk 20-30% risk >30%
CV RISK – EUROSCORE
3753 SUBJECTS ELIGIBLE TO
EUROSCORE
4%
9%
8%
1%
0% 0%0%
3%
12%
14%
5%
1%
0% 0%
5%
14%
11%
3%
0% 0% 0%
2%
4%
3%
0%
4%
8%
12%
16%
20%
<35 35-44 45-54 55-64 65-74 >=75
Years
risk 5% risk 5-10% risk 10-20% risk 20-40%
37% 34%40%
0%
20%
40%
60%
80%
100%
N=1553
ALL MEN WOMEN
N=653 N=900
% with familiarity for CVD
64
276
499 572391
13096
287
611
759
418
105
0
200
400
600
800
1000
1200
1400
< 35 35 - 44 45 - 54 55 - 64 65 - 74 ≥ 75
Years
Vis
ito
rs
Age and gender MEN
WOMEN
LIFESTYLE