1. Can lifestyle moderate the burden of CVD? Evangelos Polychronopoulos, MD, MPH, PhD Asst Professor of Preventive Medicine Harokopio University

2. The burden of CVD Cardiovascular diseases are one of the leading causes of mortality and morbidity worldwide.

3. Causes of death in Europe (2002)

7. The burden of CVD The burden is considered in terms of –morbidity, –mortality and –costs related to contemporary diseases of civilization (like the cardiovascular disease) and other non-communicable diseases.

8. Lifestyle and CVD According to WHO ranking among the top lifestyle-related risk factors are –smoking, –alcohol, –obesity and –physical inactivity.

9. Yusuf S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 “Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity account for most of the risk of myocardial infarction worldwide in both sexes and at all ages in all regions. This finding suggests that approaches to prevention can be based on similar principles worldwide and have the potential to prevent most premature cases of myocardial infarction”.

10. Lifestyle and CVD The burden of coronary heart disease is enormous and lifestyle interventions are first-line remedy for CVD prevention and treatment.

11. Smoking and CVD Smoking is estimated to cause over 22% of cardiovascular disease.

12. Smoking in Europe (2002)

13. Overweight - Obesity

15. Overweight and obesity increase the risk of coronary heart disease, ischaemic stroke, type 2 diabetes mellitus and various types of cancer. Low intake of fruit and vegetables is estimated to cause 31% of ischaemic heart disease and 11% of stroke.

16. Trichopoulou A, et al. Mediterranean diet in relation to body mass index and waist-to-hip ratio: the Greek European Prospective Investigation into Cancer and Nutrition Study. Am J Clin Nutr. 2005 Adherence to a Mediterranean diet was essentially unrelated to BMI, with small differences depending on model choice and having no practical consequences. Overweight is a genuine problem in Greece and perhaps other Mediterranean countries, but it is likely to be related to limited physical activity in conjunction with excessive positive energy balance.

17. Panagiotakos DB, et al. The association between the prevalence of obesity and adherence to the Mediterranean diet; the ATTICA study. Nutrition 2006 The prevalence of overweight and obesity in 3000 Greek adults was 53% and 20%, in men and 31% and 15% in women. –An inverse relationship was observed between Mediterranean diet score, waist-to-hip ratio (r = -0.31, p < 0.001) and BMI (r = -0.4, p < 0.001), after adjusting for sex and age.

18. Panagiotakos DB, et al. The association between the prevalence of obesity and adherence to the Mediterranean diet; the ATTICA study. Nutrition 2006 Greater adherence to the Mediterranean diet (i.e. highest tertile) was associated with 51% lower odds of being obese (odds ratio = 0.49, 95% CI 0.42 to 0.56) and 59% lower odds of being central obese (odds ratio = 0.41, 95% CI 0.35 to 0.47) as compared to a non-Mediterranean diet (i.e. lowest tertile), after controlling for age, sex, physical activity status, metabolic and other variables.

19. Physical inactivity Diverging trends of decreasing energy intake and increasing prevalence of obesity suggest that physical inactivity and sedentary lifestyle may be one of the key determinants of the growing rates of overweight/obesity in Western populations information about the impact of physical inactivity and sedentary lifestyles on the prevalence of obesity among the general adult population in the European Union is sparse.

20. Physical inactivity 3 - 7 out of 10 Europeans are physically inactive. This figure varies between country to country. 5-8% of deaths are attributable to physical inactivity in Europe.

21. How to improve physical activity status … Hillsdon & Thorogood found that interventions that encourage walking and do not require attendance at a sports or exercise facility are most likely to lead to sustainable increases in overall physical activity. Brisk walking has the greatest potential for increasing the overall activity levels of a sedentary population and meeting public health recommendations.

22. How to Implement Physical Activity in Primary and Secondary Prevention; A Statement for Healthcare Professionals From the Task Force on Risk Reduction, American Heart Association by G. Fletcher. Physical activity in primary prevention should begin in the early school years and continue throughout an individual's lifetime.

23. The NCEP ATP III suggested … … for Therapeutic Lifestyle Changes in order to reduce the prevalence of the metabolic syndrome (a risk situation and leading intermediate outcome to type 2 diabetes and coronary heart disease).

24. The NCEP ATP III suggested … These changes included the consumption of low-saturated diet (<7% of total fat) and the adoption of a physically active lifestyle. It is also very important the studies of the effect of a traditional, prudent diet, the Mediterranean diet, on the components of the syndrome, in relation to exercise.

25. Lack of data to support evidence … In spite of this fact, there is a serious lack of reliable data on lifestyle-related risk factors. The scientific efforts should be continued for internationally comparable data, “to get more insight” into real intra-national and inter-national differences obtained according to the best evidence.

26. Conclusion Lifestyle approach is a long-term way of life, a self discipline expression in terms of knowledge, skills, attitude and values in the whole lifespan for the moderation of disease burden. It is not only a compliance in primordial, primary, secondary, tertiary prevention guidelines, recommendations and medical / pharmaceutical therapy instructions.

27. Conclusion It is an extraction of philosophy (Greek wisdom and way of life). The best lifetime approach, includes a prudent diet, such as the Mediterranean diet where “balance, variety, moderation”, is an every day reality, along with mild walking, good human relations supported by a proper medical therapy.