Dr. Doug Klein Associate Professor, Department of Family Medicine University of Alberta, Edmonton, AB [email protected] 1 • I am a member of CHANGE CANADA • I receive a salary from the U of Alberta • I have not personally received any financial or other incentives from CHANGE, FITBIT or other products • I am biased to the importance of healthy eating and exercise 3 4 5 6 • Learn about a new lifestyle intervention program based primary care in Canada • MOVE • Inspire innovation to support lifestyle change • “If we could give every individual just the right amount of nutrition and exercise, not too little not too much, we would have found the safest way to health” % of Canadians 60.00% 60% of Canadians perceive their health to be either very good or excellent, an equally large group (13.5 million people) are either overweight or obese.1 50.00% 40.00% 30.00% 20.00% 10.00% 85% of Canadians fall short of the current physical activity recommendations.2 In relation to healthy eating, 60% of Canadians report eating less than 5 daily servings of fruits and vegetables.3 On any given day, 25% of Canadians will eat from a fast food outlet.4. 1. Statistics Canada, 2012 0.00% (1) 9 • • • • • • • • Depression Anxiety DM HTN Cholesterol Weight/obesity Cancer Osteoarthritis • • • • • • • Osteoporosis Fibromyalgia Fall Prevention Constipation IBS COPD Cognition • • • • 1 in 5 adult Canadians have MetS 19% Australians >25 years have MetS 40% of adults > 65 Major risk from DM, Heart Attack, Stroke, Kidney failure • CVD 11.6% of the total costs of illnesses and 13.9% of all drug prescriptions • $36 Billion in Meds Costs ONLY in Canada 11 • 7447 persons Metabolic syndrome • 3 groups: a Mediterranean diet suppl. extravirgin olive oil, a Mediterranean diet suppl. with mixed nuts, or control diet • Follow up 4.8 years • Major CV endpoints: myocardial infarction, stroke, or death • Hazard ratios were 0.70 for olive oil group, 0.72 for the nuts group compared with control P=0.015 • N Engl J Med 2013; 368:1279-1290 • MetS developed in 960 (50.0%) of the 1919 participants: no effect of the Mediterranean diet • Reversal of MetS in 958 (28.2%) of the 3392 participants who had MetS at baseline • Olive oil Group - significant decreases in both central obesity and high fasting glucose (p = 0.02) • Group supplemented with nuts showed a significant decrease in central obesity CMAJ 2014. DOI:10.1503 /cmaj.140764 13 1) RCT 101 males (~61), stable angina • PCI single vessel vs Bike to 70% HR of Sx for 10 min/d x 2 wks, then 20 min/d + one 60 min/wk • Exercise ↓ ischemic outcomes • RRR 61%, AR 18%, NNT 6, (At 50% cost). 2) Cochrane: exercise (mostly CAD rehab exercise) found 31% CAD mortality reduction 3) In CHF over 10 years, Mortality down from 16% to 6% 1) Circulation 2004;109:1371-8. 2) Cochrane 2011;(7):CD001800. 3) J Am Coll Cardiol 2012;60:1521–8. 15 • Cochrane review demonstrated 31% decrease in mortality with exercise with cardiac rehab • 101 Patients randomized to Stent or exercise protocol • > 75% stenosis with Class I-III Angina • Demonstrated Ischemia by Stress or Nuclear Scintigraphy • Maximal Medical therapy matched both groups • Triple Vessel disease in 18% Circulation 2004;109:1371-1378, Joliff et al. Cochrane Library 2002 • After 12 month of 20m/d bike +60m/wk group • Event Free survival: 88% in exercise patients versus 70% of the PCI group (p= 0.023) • Symptoms improvement in both groups, but increased exercise tolerance in the exercise group. • 15 of the exercise patients showed progression of disease versus 21 of the PCI group (p=0.035) • For patients, personal and environmental factors may inhibit Patients and positive behavioural changes. physicians alike must • For physicians, system and provider overcome barriers to barriers may stand in the way of lifestyle motivating and supporting healthy modification. lifestyle adaptations. 18 Canadian Health Advanced By Nutrition and Graded Exercise www.changealberta.net • Based in primary care in 3 Canadian cities (Edmonton, Toronto, Laval) • Supported by kinesiologists and dietitians to implement nutritional modification and graded exercise over 1 year 1. Reduce components of the Metabolic syndrome. 2. Reduce reliance on pharmacological drug use. • Focus of this project • confirming that the intervention is effective; • acceptance of the lifestyle intervention; • ability to recruit patients, and; • usability of protocol tools and materials. CHANGE Participants Numbers of Patients Age, years BMI, kg/m2 Waist circumference, cm Metabolic Syndrome Criteria Blood pressure≥ 130/85, mmHg Tx with anti-HTN meds Glucose > 5,6, mmol/L Tx with hypoglycemic meds TG > 1.7 mmol/L Increased Waist Circumference HDL-C < 1.0 M and < 1.3 F, mmol/L 307 (51% F) 59.1 ± 9.7 31.8 ± 3.4 107.7 ± 9.8 93 (30.4%) 222 (72.5%) 238 (77.5%) 126 (41%) 188 (61.2%) 294 (95.8%) 144 (46.9%) 21 • Reversal of MetS in 18.0 % of the participants after 3 months, 25.5% after 6 months and 28% after 9 and 12 months. • Reversal of >1 MetS criteria was observed in 42%, 47%, 51%, 52.4% of patients at 3, 6, 9 and 12 months respectively • Patient attendance 88% and 96% of prescribed visits to the dietitian and kinesiologist. • The average PROCAM derived 10-year risk of acute coronary events was 8.9% at baseline (N=104). The mean (SD) change from baseline to 12 months was an decrease of 1.3% (SD=2.9%). This is a relative risk reduction of 18.6% • Among the participants from the CHANGE pilot project with a PROCAM derived 10-year risk of CVD currently available at baseline and 12 months and a baseline score >10% (N=54), the average risk has decreased 16% to 11% (a clinically significant relative risk reduction of 31%). 23 Absolute Change in PROCAM Risk Score after 12 months (n=138) 20 15 Absolute Change (%) 10 5 0 0 5 10 15 20 25 30 35 -5 -10 -15 -20 -25 Baseline PROCAM Risk Score (%) 24 • Focus Groups with CHANGE participants • Support and involvement by participants’ family physicians along with regular meetings with the dietitian and kinesiologist act as key motivators. • Importance of external motivators at the beginning of the program and then within two to four weeks their internal motivators (“feels great” and “it has changed my life”) became the primary motivators for adhering to the program. • Primary Care Survey • Most PCNs have dieticians (78%) and kinesiologists (70%) as part of their existing teams • Most Alberta PCNs (82%) indicated that, if funded, they would implement CHANGE in their PCN. • 16 PCNs are interested in participating (providing care for 50% of the Alberta population). 25 • E- CHANGE – e-health technologies Funded by CIHR • CHANGE CANCER AB – Funded by Alberta Cancer Legacy Fund • CIHR cRCT – Bridge Funding from CIHR, Full funding decision is pending 26 • Hypothesis: Patients with MetS who are followed by a team consisting of a FD, DIET, and KIN, can achieve greater reversal of MetS and greater reduction in 10 year CVD risk at 12 months compared to patients who undergo usual care. • Design: A multicenter, cluster-randomized, comparative effectiveness trial. • Setting: 16 PCNs in Alberta, Canada that have a FD, DIET and KIN available to help manage patients with MetS. • Study Population: Adult patients identified by their FD as having MetS and a PROCAM risk for CVD > 10%. • Sample Size and Duration: 960 patients from 16 sites over 5 years • Outcomes: The primary outcome will be the number of patients who have a reversal of MetS (no longer meeting 3 of 5 diagnostic criteria) after 12 months of the intervention. The secondary outcome will be the number of patients with MetS who achieve greater reduction in 10 year CVD risk after 12 months of the intervention. Additional outcomes of this trial include self reported physical and mental health (SF-12), current physical activity, dietary behaviour, program costs, and adherence to the program. • Follow-up: All patients will be followed for 12 months intervention and an 27 addition 12 month post-intervention follow-up. Time to Walk the Walk 28 MOVE • This community-based program encourages participants to be active outside–no need to go to a gym or buy any exercise equipment. • www.moveyeg.ca • @moveyeg 31 • A group of patient connected electronically to encourage physical activity and achieving personal health goals • Turns keeping active into a game • Competition is Healthy 33 • Learn a new exercise each week. • We describe and provide images for each exercise so you can learn to do it properly. • Exercises are taught in the PCN gym, repeat at weekly MOVE sessions and are on-line to be an ongoing resource to patients Feel free to contact me at [email protected] 37
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