1. Nutrition –Health Alliance ‘NUTRIHEAL’ Meditterranean-type Nutrition Intervention Program for patients with Cardiometabolic Diseases Maria Hassapidou Professor of Nutrition and Dietetics,ATEITH,Thessaloniki,Greece Fi Financed by NSRF Reference Framework (NSRF) 2007 -2013ΝNNational Strategic Reference Framework (NSRF) 2007 -2013National Strategic Reference Framework (NSRF) 2National Strategic Reference Framework (NSRF) 2007 -2013007 -2013 National Strategic Reference Framework (NSRF) 2007 -2013 -.

2. The rapid increase of cardiometabolic diseases (obesity, type II diabetes, dyslipidemia, hypertension, cardiovascular diseases)in Greece,the last decades leading to increased morbidity and mortality and the related health care costs made a necessity the development and implementation of intervention strategies targeted to the needs of specific population groups.

3. Recent data show that one third of Greeks are obese, 10% suffer from diabetes and one third has hypertension. Greece has still an upward trend for cardiovascular morbidity and mortality, in contrast to most European countries where it has been stabilized or is decreasing and this is mainly due to the abandonment of the traditional way of eating and living. From the few data available for our country, cardiovascular diseases represent 10% of total health care costs, which is equivalent to 1,922,000 euros annually. Indirect economic costs include the cost of lost productivity due to morbidity and premature mortality.

4. The abandonment of the Mediterranean diet and the adoption of Western dietary model, i.e. food that is high in calories,saturated and trans fats, salt and sugars and low in fiber and antioxidants is the major factor for the rapid increase of cardiometabolic diseases in Greece. Paletas K. et al.,Jour of the American College of Nutrition. 2010;29(1) :41-45 Trichopoulou A et al.,Arch Intern Med. 2005;165 (8) : 929-935

5. The combination of diet and physical activity may reduce cardiovascular risk by about 82%, while a healthy diet alone by 60%. Specifically, regarding the risk factors, proper healthy diet can reduce body weight by about 10 % or more -depending on the case-, blood pressure by 10 mmHg, LDL cholesterol by 20% and in combination with behavior modification can reduce the risk of type 2 diabetes by 58%. Bertsias G et al et al., BMC Public Health. 2003,3 :3 Kapantais E et al. Ann Nutr Metab. 2006;50:330-338 Roditis M et al., Jour of Pediatric Endoc and Matab, 2009,22,389-405

6. Esruch et al,2006 Vincent-Baudry et al., 2005 Esposito et al., 2004 Michalsen et al., 2006 Toobert et al., 2003

7. Esruch et al,2006 Vincent-Baudry et al., 2005 Esposito et al., 2004 Michalsen et al., 2006 Toobert et al., 2003 Body weight reduction

8. Table 1. Summary of lifestyle intervention to prevent diabetes and reduce CVD risk (Horton,2009) AuthorStudy (country) Population (age, BMI) Conditio n Duration Follow-up InterventionRelative risk reduction T2DM vs. controls Pan et al.,1997 Da Qing Study (China) 577 (45 years, 25.6 kg/m 2 ) IGT6 yearsEX only EX + DIET DIET only 47% 38% 33% Tuomilehto et al., 2001 Diabetes Prevention Study (Finland) 522 (55 years, 31.0kg/m 2 ) IGT3.2 yearsEX + DIET58% Knowler et al., 2002 Diabetes Prevention Program (USA) 3234 (51 years, 34.0kg/m 2 ) IGT2.8 yearsEX + DIET Metformin 58% 31% Bray et al., 2006 Look Ahead Trial (USA) 5145 (59 years, 36kg/m 2 ) T2DM1 year (until today) EX + DIETN/AN/A ΕΧ: Exercise DIET: Dietary Treatment

9. Table 1. Summary of lifestyle intervention to prevent diabetes and reduce CVD risk (Horton,2009) AuthorStudy (country) Population (age, BMI) Conditio n Duration Follow-up InterventionRelative risk reduction T2DM vs. controls Pan et al.,1997 Da Qing Study (China) 577 (45 years, 25.6 kg/m 2 ) IGT6 yearsEX only EX + DIET DIET only 47% 38% 33% Tuomilehto et al., 2001 Diabetes Prevention Study (Finland) 522 (55 years, 31.0kg/m 2 ) IGT3.2 yearsEX + DIET58% Knowler et al., 2002 Diabetes Prevention Program (USA) 3234 (51 years, 34.0kg/m 2 ) IGT2.8 yearsEX + DIET Metformin 58% 31% Bray et al., 2006 Look Ahead Trial (USA) 5145 (59 years, 36kg/m 2 ) T2DM1 year (until today) EX + DIETN/AN/A ΕΧ: Exercise DIET: Dietary Treatment

10. Given the lack of national programs targeted in nutrition education for adults and elders in Greece, the proposed project “Nutriheal” includes targeted actions for adults and elders with cardiometabolic diseases, which are based on tested interventions internationally. The program is expected to improve health and quality of life of the diseased, as well as the healthy (at the level of prevention) population. The expected impact is summarized in reducing morbidity and associated health care costs of people by improving their diet. Objective of the Project

11. Objectives of the Project Nutritional Education Intervention Program Nutriheal reduction of cardiometabolic diseases Improvement of level of health reduction in direct and indirect economic costs reduction of lost productivity

12. The intervention program is carried out by Greek dietitians. Fifteen dietitians are participating in the program. Each dietitian is responsible for three municipalities. Methodology

13. . r 6 months. The intervention group (I) received a M All Subjects were randomized into 2 groups and followed for 6 months. The intervention group (I) received a Mediterranean-type healthy diet personalized in calories and nutrients according to the patient’s diseases, and followed monthly by a dietitian, and the control group (C) did not receive any dietary counseling.ng Methodology

14. Measurements : BMI %Body Fat (%BF) by BIA waist circumference(W) serum lipids (TC,TG,LDL-C,HDL-C) Fasting plasma glucose (FPG) HBA1c (only in diabetic patients) Systolic (SBP) and Diastolic (DBP) blood pressure Methodology

15. Deliverables:  Literature review with detailed and evidenced based methodology.  Electronic file with the organizational chart of the intervention  Information/Education material. Workpackage 1: Design and Implementation of Intervention Programs Work Package 1.1: Literature review & design of intervention programs

16. Diet and Obesity

17. Principles of Healthy Nutrition

18. NUTRITION AND HYPERLIPIDEMIA NUTRITION AND CARDIOVASCULAR DISEASE

19. Nutrition and Diabetes Nutrition and Hypertention

20. Work Package 1.2: Raising awareness of health professionals regarding nutrition and healthy lifestyle  There will be 5 seminars in each municipality of awareness for health professionals (doctors, nurses, physiotherapists, social workers, sports scientists) about nutrition and healthy lifestyles.  One seminar will be organised in each municipality for the general public about the role of nutrition in prevention and treatment of cardiometabolic diseases and the way to help patients to change their nutritional behaviour.

22.  Intervention programs are implemented in 50 municipalities in Greece selected by random sampling. The intervention is taking place in groups according to age (25-44, 45-65 and over 65 years)and disease (Obesity, type II diabetes,hyperlipidemia, hypertension, and cardiovascular disease) with ten meetings- interventions in each age group.  Intervention is carried out by dietitians and diet treatment is based on the Mediterranean diet model and personalised according to age, sex, disease and dietary needs. Work Package 1.3: Intervention programs in Municipalities for patients with cardiometabolic diseases.

23. Deliverables: -Intervention programs in municipalities (50 in total) in three age groups (a total of 90 persons per municipality, 60 adults and 30 elders) for five cardiometabolic diseases (obesity, type II diabetes, dyslipidemia, hypertension, cardiovascular disease). Each intervention includes individualized counseling in at least 5 meetings. Therefore 5x50x90 = 22500 total sessions will be implemented (30 min each). -Database of dietitians, doctors university professors, scientific societies, hospital departments & clinics that are related to the treatment of cardiometabolic diseases as well as links of municipalities, associations of patients (e.g. diabetics) and other relevant bodies. Work Package 1.3: Intervention programs in Municipalities for patients with degenerative diseases.

24. Workpackage 2 aims to the promotion of intervention activities that include: Production of radio spots, with emphasis on radio repeated messages at local level to increase the involvement both of health professionals in the awareness seminars, and of the general public and the patients in the intervention programs. Publications in local electronic and printed media, magazines and daily newspapers. Dissemination of results (publications, presentations in special conferences, seminars and scientific events) Web site Social media Workpackage 2: Dissemination and promotion of the project activities

28. Base line characteristics of the participants Men (n = 693)Women (n=2525) Age (yrs) 56.34  15.4754.67  13.77 Body Weight (Kg) 97.69  19.73** a 84.44  17.38** a Body Height (m) 1.74  0.07** b 1.60  0.007** b Body Fat (%) 32.67  8.20** c 41.90  7.21** c BMI 32.32  5.89* d 32.84  6.55* d Waist circumference (cm) 111  13** e 103  14** e Hip circumference (cm) 110  10** f 113  13** f WHR 1.01  0.09** g 0.91  0.10** g Neck circumference (cm) 42  4** h 36  3** h * p<0.05**p<0.001 *p<0.05 **p<0.001

29. Total Diseases

30. Total Diseases Men and Women

31. Walking Assessment (Men) Walking≥ 210min/weekWalking <210min/week Age (yrs) 58.59  14.02* a 55.41  15.95* a Body Weight (Kg) 93,44  16.70** b 99.46  20.62** b Body Height (m) 1.73  0.071.74  0.07 Body Fat (%) 31.82  7.6633.02  8.40 BMI 31.10  4.73** c 32.82  6.24** c Waist circumference (cm) 108  13* d 112  13* d Hip circumference (cm) 108  9** e 111  10** e WHR 1.00  0.081.00  0.09 Neck circumference (cm) 41  342  4 *p<0.05**p<0.001

32. Biochemical measurements and exercise (Men) Walking≥ 210min/weekWalking <210min/week Total cholesterol (mg/dL) 196  41199  38 LDL cholesterol (mg/dL) 124  38122  33 HDL cholesterol (mg/dL) 47  13** f 50  16** f Triglycerides (mg/dL) 140  70139  59 Glucose (mg/dL) 114  44112  33 Glycosylated (mg/dL) 6.83  3.116.62  2.10 Systolic blood pressure 129  14131  16 Diastolic blood pressure 83  1282  11 Sitting (hours/week) 38.55  20.89* g 43.30  29.24* g *p<0.05**p<0.001

33. Total Men

34. In the total sample (n = 3218): In men walking was negatively associated with hip circumference (-,088, p<0.05). In women walking was associated with body weight (-,062, p<0.05), BMI (-,046, p<0.05), waist circumference (-,063, p<0.001), WHR (-,062, p<0.001), neck circumference (-,049, p<0.05) and triglycerides (-,069, p<0.001).

35. In the total sample (n = 3218): Walking presented statistical significant negative correlation with BMI (-,047, p<0.001), waist circumference (-,036, p<0.001), hip circumference (-,040, p<0.05) and triglycerides (-,058, p<0.001).

36. Assessment of intervention Intervention before (N229) Intervention after (N229) Control before (N122) Control after (122) Body Weight (Kg) 88.80  17.18** a 84.44  17.38** a 88.81  19.0989.58  20.64 Body Fat (%) 40.23  7.7340.06  8.0538.15  7.6938.51  7.77 BMI 34.29  6.01** b 33.58  5.88** b 32.34  5.9132.59  6.18 Waist circumference (cm) 105  14** c 103  14** c 106  16106  15 Hip circumference (cm) 115  12** d 113  11** d 115  13114  12 WHR 0.91  0.10 0.92  0.110.93  0.11 Neck circumference (cm) 37  3 38  439  4 *p<0.05**p<0.001

37. Assessment of intervention Intervention before (N229) Intervention after (N229) Control Before (N122) Control after (N122) Total chol (mg/dL) 206  41** e 195  34** e 204  44** a 211  45** a LDL chol (mg/dL) 128  34** f 119  31** f 128  38132  37 HDL chol (mg/dL) 54  1555  1449  1448  12 Triglycerides (mg/dL) 134  58* j 124  49* j 142  59147  85 Glucose (mg/dL) 109  25** k 105  22** k 104  29105  22 Systolic blood pressure 126  11125  11126  11125  31 Diastolic blood pressure 81  9 82  1082  9 *p<0.05**p<0.001

38. Body Weight Change

39. BMI Change

40. Waist and Hip circumference changes Waist Hip

41. Total Cholesterol LDL Cholesterol

42. Triglycerides Glucose

43. Conclusion In conclusion, preliminary data from this nutrition intervention study in Greek municipalities carried out by dietitians suggest that a well balanced Mediterranean-type diet is able to reduce several metabolic risk factors in patients with CM diseases. It also showed the essential role of dietitans in communities in health prevention and in dietary intervention programs.