Dr. Doug Klein
Associate Professor, Department of
Family Medicine
University of Alberta, Edmonton, AB
[email protected]
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• 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
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• 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)
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Depression
Anxiety
DM
HTN
Cholesterol
Weight/obesity
Cancer
Osteoarthritis
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Osteoporosis
Fibromyalgia
Fall Prevention
Constipation
IBS
COPD
Cognition
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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
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• 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
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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.
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• 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.
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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%)
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• 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%).
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Absolute Change in PROCAM Risk Score after 12 months (n=138)
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Absolute Change (%)
10
5
0
0
5
10
15
20
25
30
35
-5
-10
-15
-20
-25
Baseline PROCAM Risk Score (%)
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• 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).
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• 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
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• 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
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addition 12 month post-intervention follow-up.
Time to Walk the Walk
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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
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• A group of patient
connected electronically
to encourage physical
activity and achieving
personal health goals
• Turns keeping active into
a game
• Competition is Healthy
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• 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]
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