1. EUROACTION: Changes in diet and physical activity over one year in a family based preventive cardiology programme in hospital and general practice Jennifer Jones on behalf of the EUROACTION study group Department of Cardiovascular Medicine, Imperial College, London, UK

2. The Multidisciplinary family based EUROACTION Programme In hospitals for coronary patients and their families In primary care for individuals at high risk of developing cardiovascular disease and their partners

3. EUROACTION 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.

4. EUROACTION EUROACTION Study design A cluster randomised controlled trial in hospital and general practice with clinical follow-up at 16 weeks and 1 year

5. 8 countries 24 centres 10,000+ subjects EUROACTION

6. Generalisable model of preventive cardiology care

7. Nurse-led multidisciplinary approach The EUROACTION team in Boldrini Hospital, Thiene, Italy The EUROACTION nurse and the lead GP in Hoensbroek, The Netherlands

8. Identification and recruitment Multi-disciplinary initial assessment Preventive Cardiology Programme Empowering families to change their lifestyle: smoking, diet and physical activityEmpowering families to change their lifestyle: smoking, diet and physical activity Blood pressure, blood cholesterol and blood glucose managementBlood pressure, blood cholesterol and blood glucose management 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 (hospital only) One year follow-up Structure of the Programme in Hospital and Primary Care

9. Smoking cessation Increasing Physical activity Healthy eating, Weight management Lifestyle change No smokingNo smoking Saturated Fat: <10% total EnergySaturated Fat: <10% total Energy Fruits and vegetables: >400g/dayFruits and vegetables: >400g/day Fish: >20g/dayFish: >20g/day Oily Fish: >3 times/weekOily Fish: >3 times/week 30-45 minutes of physical activity at 60–75% of the average maximum heart rate on four-five days of the week30-45 minutes of physical activity at 60–75% of the average maximum heart rate on four-five days of the week Weight reduction ≥ 5%Weight reduction ≥ 5% Waist <94 cm in men and <80 cm in womenWaist <94 cm in men and <80 cm in women

10. Aim of the dietary intervention 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

11. Dietary 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

12. If weight loss identified as 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

13. Physical 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

14. Thiene, Italy Valencia, Spain The Supervised Exercise Programme in Hospital  Non-equipment based weekly supervised programme  Tailored physical activity advice  Monitored  Progressive  Identification of local facilities  Philosophy of empowerment

15. Physical Activity Advice in Primary Care    Facilities    Specialist schemes    Experts    Activities available

16. Educational Materials Goal setting and tracking progress with the Personal Record Card

17. RESULTS

18. Index Event: Coronary Patients 69.9 % Male Mean age overall 62.5 years High Risk Patients 49.8 % Male Mean age overall 62.0 years

19. One year assessment One year assessment Identification Participation in the Programme Intervention PATIENTS 946 (89%) ** Hospital Arm Initial assessment 307 1061 (67%)* 1694 828 646 401 1718 994 802 335 PARTNERS PATIENTS PARTNERS Usual Care 860 (82%) ** 410 *Of those eligible **Of those who attended initial assessment

20. One year assessment One year assessment Identification Participation in the Programme Intervention PATIENTS 1019 (91%)** Primary Care Arm Initial assessment 331 1118 (89%)* 1257 805 261 225 1752 1005 830 NA 363 PARTNERS PATIENTS PARTNERS Usual Care 947 (85%)** 204 *Of those eligible **Of those who attended initial assessment

21. Change in proportion of patients achieving the European targets for a healthy diet from initial assessment to 1 year Coronary Patients High Risk Patients +23.6% (9.1 to 38.2)* +16.5% (-0.1 to 33.1) +15.8% (2.2 to 29.3)* +11.8% (-2.1 to 25.6) (-2.1 to 25.6) +11.4% (0.6 to 22.1)* (0.6 to 22.1)* +2.2% (-1.7 to 6.2)  Intervention  Usual Care * p<0.05

22. High Risk Patients + 32.9% (1.8 to 53.9)* Coronary Patients + 28.1% (13.9 to + 42.3)* Change in proportion of patients participating in moderate intensity activity ≥4 times/week ≥30minutes from initial assessment to 1 year  Intervention  Usual Care * p<0.05

23. High Risk Patients Coronary Patients Mean change in BMI in those ≥25kg/m² and from initial assessment to 1 year** -0.69 kg/m² (-1.03 to -0.34)* -2.8 kg/m² (-13.1 to +7.5)  Intervention  Usual Care * p<0.05 **random subsample in usual care

24. High Risk Patients Coronary Patients Mean change in waist circumference in men ≥94cm and women ≥80cm from initial assessment to 1 year** -0.8 cm (-3.7 to 2.1) -1.61 cm (-2.61 to -0.61)*  Intervention  Usual Care * p<0.05 **random subsample in usual care

25. *OR 0.70 (0.53 to 0.93), p=0.02 General Practice General Practice Hospital Hospital Distribution of Waist Circumference at One year – All Patients *OR 0.61 (0.39 to 0.97), p=0.04 *Proportional odds model

26. Conclusions nurse-led multidisciplinary family lifestyle changes healthy diet physical activity The nurse-led multidisciplinary EUROACTION family based programme achieved significantly better lifestyle changes for coronary and high risk patients in terms of a more healthy diet, reduction in abdominal obesity and increased physical activity compared to usual care.

27. Conclusions EUROACTION has set new standards of preventive cardiology care for coronary and high risk patients and their families in everyday clinical practice

28. EUROACTION A European Society of Cardiology demonstration project in preventive cardiology www.escardio.org/euroaction solely sponsored by an unconditional educational grant from Astra Zeneca