1. DAGLI STILI DI VITA AI FARMACI ( O DAI FARMACI AGLI STILI DI VITA?) Dr. Brunello Cappelli

2. Prevalence of Overweight* P=0.04 S2 vs. S1 : P=0.15 S3 vs. S2 : P=0.22 S3 vs. S1 : P=0.02 * Body mass index 25 kg/m²

3. Prevalence of Obesity* P=0.0006 S2 vs. S1 : P=0.009 S3 vs. S2 : P=0.051 S3 vs. S1 : P=0.0002 * Body mass index 30 kg/m²

4. Prevalence of Central Obesity* * Waist circumference 102 cm in men or 88 cm in women P<0.0001 S2 vs. S1 : P=0.0001 S3 vs. S2 : P=0.47 S3 vs. S1 : P<0.0001

5. Prevalence of Diabetes* P=0.004 S2 vs. S1 : P=0.21 S3 vs. S2 : P=0.02 S3 vs. S1 : P=0.001 * Self-reported history of diagnosed diabetes

6. Therapeutic Control of Diabetes* P=0.04 S2 vs. S1 : P=0.82 S3 vs. S2 : P=0.03 S3 vs. S1 : P=0.08 * Fasting glucose < 7 mmol/L in patients with history of diabetes

7. Prevalence of Smoking* P=0.64 S2 vs. S1 : P=0.83 S3 vs. S2 : P=0.37 S3 vs. S1 : P=0.48 * Self-reported smoking or CO in breath > 10 ppm

8. Prevalence of Raised Blood Pressure (1)* P=0.79 S2 vs. S1 : P=0.83 S3 vs. S2 : P=0.51 S3 vs. S1 : P=0.65 * SBP 140 mmHg and/or DBP 90 mmHg

9. Medication Use: ACE Inhibitors & Angiotensin II RA P<0.0001 S2 vs. S1 : P<0.0001 S3 vs. S2 : P<0.0001 S3 vs. S1 : P<0.0001

10. Medication Use: Beta-Blockers P<0.0001S2 vs. S1 : P=0.001 S3 vs. S2 : P=0.0002 S3 vs. S1 : P<0.0001

11. Medication Use: Antiplatelets P<0.0001S2 vs. S1 : P=0.29 S3 vs. S2 : P=0.0002 S3 vs. S1 : P<0.0001

12. Medication Use: Statins P<0.0001 S2 vs. S1 : P<0.0001 S3 vs. S2 : P<0.0001 S3 vs. S1 : P<0.0001

13. Prevalence of Raised LDL Cholesterol* P<0.0001 S2 vs. S1 : P=0.001 S3 vs. S2 : P<0.0001 S3 vs. S1 : P<0.0001 LDL C 2.5 mmol/L for patients fasting for at least 6 hours

14. Conclusioni dall EUROASPIRE surveys I risultati relativi ai trends temporali di variazione dello stile di vita sono decisamente sconfortanti: dimostrano come sia difficile per un adulto cambiare abitudini di vita ma rispecchiano anche la limitatissima attenzione riservata dai medici alla prevenzione non farmacologica (Guy De Baker, coordinatore nazionale per il Belgio di Euroaspire) I pazienti hanno bisogno di un supporto professionale per modificare il loro stile di vita e per correggere i loro fattori di rischio in maniera più efficace. Limitarsi a mettere loro in mano una ricetta non basta (David Wood, principal investigator di Euroaspire)

15. Conclusions A handful of pills is not enough Professor David A Wood on behalf of the EUROASPIRE Investigators

18. Obesity Trends* Among U.S. Adults: BRFSS, 1988 Mokdad A.H., CDC (*BMI > 30, or ~ 30 lbs overweight for 54 woman)

19. Obesity Trends* Among U.S. Adults: BRFSS, 1994 Mokdad A.H., CDC (*BMI > 30, or ~ 30 lbs overweight for 54 woman)(*BMI > 30, or ~ 30 lbs overweight for 54 oman)

20. Obesity Trends* Among U.S. Adults: BRFSS, 2000 Mokdad A.H., CDC (*BMI > 30, or ~ 30 lbs overweight for 54 woman)

22. Patient BMI Obesity Management in an Outpatient Office Practice 3737 2929 3333 2121 4040 3131 2727 2020

24. 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%

25. 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%

26. 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%

28. NHANES III Prevalence of Hypertension* According to BMI *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.

29. JACC 2008 52:979-985 The CRUSADE registry

30. 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

33. La pratica delle attività fisico-sportive oggi Larea totale dei cittadini attivi stimata dallIstat-circa 36 milioni nel 1999,si è ridotta nel 2003 a circa 32 milioni e mezzo, mentre larea della sedentarietà è salita da 19,5 a 23 milioni (sugli abitanti da 3 anni in su). AMSAMS

34. Weight Reduction Energy Intake < Energy Expenditure

35. 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 practical way to reduce calories. Evidence Category A.

36. 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.

37. Metabolic Influence Reduction of obesityReduction of obesity Enhanced glucose toleranceEnhanced glucose tolerance Improved lipid profileImproved lipid profile Metabolic Influence Reduction of obesityReduction of obesity Enhanced glucose toleranceEnhanced glucose tolerance Improved lipid profileImproved lipid profile Lifestyle Influence Decreaded likelihood of smokingDecreaded likelihood of smoking Possible reduction of stressPossible reduction of stress Short term reduction of appetiteShort term reduction of appetite Lifestyle Influence Decreaded likelihood of smokingDecreaded likelihood of smoking Possible reduction of stressPossible reduction of stress Short term reduction of appetiteShort term reduction of appetite Possible Biological Mechanisms for Exercise- Induced Reductions in All-Causes and Cardiac Mortality

38. Increased physical activity with or without weigth reduction,improves insulin action and reduces insulin resistance in obese persons. (evidence A) Endurance exercise training when combined with weigth loss of > 4-5 Kg improves the lipid- lipoprotein profil by raising HDL cholesterol and lowering trigliceridis among overweigth and obese men and women. (evidence A) Dynamic aorobic physical activity with or without weigth loss,reduces blood pressure among overweigth and obese with the greatest effect seen among persons with hypertension. (evidence A) Increased physical activity with or without weigth reduction,improves insulin action and reduces insulin resistance in obese persons. (evidence A) Endurance exercise training when combined with weigth loss of > 4-5 Kg improves the lipid- lipoprotein profil by raising HDL cholesterol and lowering trigliceridis among overweigth and obese men and women. (evidence A) Dynamic aorobic physical activity with or without weigth loss,reduces blood pressure among overweigth and obese with the greatest effect seen among persons with hypertension. (evidence A) Exercise as Therapy: Evidence Based Sport Medicine D.MacAuley,T.B Best 2002

39. 4 -10 -12 -16 -14 2 0 -2 -4 -6 -8 Systolic BP Diastolic BP All 48 All 48comparisons comparisons 14 comparisons 14 comparisons In hypertensives In hypertensives 14 comparisons 14 comparisons In hypertensives In hypertensives 7 comparisons 7 comparisons In Border Line In Border Line hypertensives hypertensives 7 comparisons 7 comparisons In Border Line In Border Line hypertensives hypertensives 27 comparisons 27 comparisons In normotensives In normotensives 27 comparisons 27 comparisons In normotensives In normotensives Net BP effect in intervention compared to control with 95% confidence interval (mmHg) with 95% confidence interval (mmHg) Net BP effect in intervention compared to control with 95% confidence interval (mmHg) with 95% confidence interval (mmHg) J.Appl.Phys 1997 Reduction of resting blood pressure

40. Relationship Between Physical Activity and Maintenance of Weight Loss Not Maintained Subjects Exercising (%) P<0.001 Kayman et al. Am J Clin Nutr 1990;52:800. Weight Loss Pattern Maintained

41. Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body Weight in Children 6-12 Years Old 0 Time (months) Decreased Sedentary Activity Change in Percent Overweight Increased Physical Activity Epstein et al. Health Psychol 1995;14:109. 4812

42. Piramide dell attività fisica Incrementare l Esercizio fisico quotidiano Ridurre il sedentarismo Promuovere l attività fisica Favorire la pratica dello SPORT

43. ACSM/AHA 2007 Recommendations Physical Activity and Public Health Circulation 2007;116-1081-1093 William L H, Russel R.P...... Moderate-Intensity Aerobic activity for at least 30 min day for 5 days a week......Vigorous-intensity activity for 20 min three days each week

44. Risk factor% Cont % CasesOR (99% CI) adj for age, sex, smok OR (99% CI) adj for all ApoB/ApoA-1 (5 v 1)20.033.53.87 (3.39, 4.42)3.25 (2.81, 3.76) Curr smoking26.845.22.95 (2.72, 3.20)2.87 (2.58, 3.19) Diabetes7.518.43.08 (2.77, 3.42)2.37 (2.07, 2.71) Hypertension21.939.02.48 (2.30, 2.68)1.91 (1.74, 2.10) Abd Obesity33.346.32.22 (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 daily42.435.80.70 (0.64, 0.77)0.70 (0.62, 0.79) Exercise19.314.30.72 (0.65, 0.79)0.86 (0.76, 0.97) Alcohol Intake24.524.00.79 (0.73, 0.86)0.91 (0.82, 1.02) All combined--129.2 (90.2, 185.0) All combined (extremes)333.7 (230.2, 483.9) INTERHEART Risk of AMI associated with Risk Factors in the Overall Population

45. INTERHEART Risk of AMI with Multiple Risk Factors SmkDMHTNAPoB/A1+2+3all4+O+PSAll 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% CI)