Παρουσίαση μου στα πλαίσια του Consensus Meeting: "Η διαχείριση και ο έλεγχος των Μείζονων Συμπεριφορικών Παραγόντων Κινδύνου για την Υγεία: η συμβολή νέων "εργαλείων" για την αντιμετώπιση τους", Ελληνική Επιστημονική Εταιρεία Οικονομίας και Πολιτικής της Υγείας, Ξυλόκαστρο 6-8 Ιουλίου 2018

1. Η διαχείριση των μειζόνων συμπεριφορικών
παραγόντων κινδύνου στην ΠΦΥ
Ευάγγελος Α. Φραγκούλης, MD, MSc
Γενικός/ Οικογενειακός Ιατρός
Αντιπρόεδρος Β’ ΕΛΕΓΕΙΑ
Council Member European Primary Care Cardiovascular Society

3. Burden of Disease Attributable to Selected Behavioral and Dietary Risk Factors in 2010
and the Metabolic and Physiological Mediators of Their Hazardous Effects.
N Engl J Med 2013;369:954-64

8. HEARTS Technical package for cardiovascular disease management in primary health care:
healthy-lifestyle counselling; Geneva: World Health Organization; 2018

10. Prevention is better than cure
• Prevention is the key to avoid
ill health and achieve a high
level of mental and physical
well-being effectively and
efficiently
• A shift in focus from sickness
and cure to prevention and
the social determinants of
health is needed
State of Health in the EU. ec.europa.eu/health/state

13. Clustering of lifestyles and its impact on mortality

15. Breaking the vicious
cycle of
ill health and poverty
https://ec.europa.eu/health/sites/health/files/state/docs/ec.europa.eu/health/state

16. Cupples M. How to initiate a long-lasting behavioural change: do’s and don’ts. Europrevent2017

24. “Enlisting the help of the largest health care workforce :
the patients”
J Cleland JAMA 2010

25. Population based strategies
• health promotion and health protection
physical, social, economic and regulatory actions that
influence the environment at population level
• reducing the availability, affordability and promotion of
foods high in saturated fats, free sugars and/or salt
• raising public awareness about healthy diets and physical
activity
• creating enabling environments for healthy choices and
active lives

26. Importance of PHC
• a unique and important role in motivating and assisting patients'
healthy behavior changes.
• people with a usual source of health care are more likely than those
without to receive a variety of clinical preventive services
• wide population coverage
Impact = Participation Rate x Efficacy
• continuous patient– provider interactions
life-long exposure to risk factors, chronic nature of these diseases
• Continuity of care offers opportunities to sustain individual
motivation, assess progress, provide feedback, and adjust behavior
change plans

27. Individual services in Primary Care
• addressed mainly to high-risk or affected
individuals
• direct interventions to prevent and treat diseases
• opportunistic risk stratification (including
anthropometric and behavioural assessments)
• provision of tailored advice
• motivational support for behaviour change
• individual and group counselling

28. Effectiveness of DAW services provided in PHC
• proven to help patients in making useful changes in their diet
and their physical activity and in managing their weight in the
short term to prevent the onset of NCDs
• less evidence of a longer-term effect on weight and mortality
• counselling individuals at risk in primary care is one of the most
expensive strategies, estimated at US$ 15 per capita, as compared
with, for example, US$ 0.10 for restrictions on the marketing of food to children
• favourable cost–effectiveness ratio (< US$ 50.000 per DALY) as
compared with treatment of NCDs (such as CVDs)

29. Βarriers to preventive service delivery in PHC
• A focus on symptom-driven, acute illness care
• Lack of defined scope of practice
• Lack of time- inadequate capacity of primary care providers to
address patient needs
• Inadequate clinician training - knowledge and competence
• Inadequate reimbursement- absence of incentives for wider
implementation
• Low patient demand
• Lack of supportive resources- clear clinical recommendations,
referral systems / appropriate patient pathways for
coordinated care and access to specialized advice, information
technology infrastructure and tools (mobile and e-health
applications and web-based interventions)
Integrating diet, physical activity and weight management services into primary care. WHO Europe 2016

31. Lack of dedicated clinical guidelines and
protocols for primary care

32. Challenges for individual services in PHC
• selection of cost–effective services in certain
contexts
• knowledge- and capacity-building for primary
care providers
• alignment with other health system functions to
ensure sustainability.

34. DAW services delivered to high-risk populations in PHC
are the most effective and cost–effective.
• Risk stratification opportunistically (independently of the
primary cause of a visit) or at a patient’s request
• Anthropometrics (weight, height and waist circumference)
• measurement of blood pressure
• collecting information on behaviour, such as diet and
amount of daily physical activity
• calculation of values associated with risk such as body
mass index (BMI), waist–hip ratio, prediction of 10-year
cardiovascular risk (Heart Score)

35. • JAMA.2017;318(2):167-
174.doi:10.1001/jama.2017.7171
JAMA.2017;318(2):167-174.doi:10.1001/jama.2017.7171

46. Michie et al. Implementation Science 2011, 6:42

47. Michie et al. Implementation Science 2011, 6:42

48. Cognitive Behavioural Therapy (CBT)
• self-motivation
• goal-setting
• self-monitoring of behaviour and progress (e.g. dietary or
activity records)
• control the process of eating and stimulus control (e.g.
portion size)
• relaxation
• slowing the rate of eating
• ensuring social support
• problem-solving
• cognitive restructuring (modifying thoughts)
• reinforcement of changes
• relapse prevention
• strategies for dealing with re-gaining weight

49. Motivational interviewing
• a counselling technique for achieving a
certain goal through a patient-centred
approach
• most people experience some mixed feelings
about change- some reasons to change and
also some reasons for staying the same, and
may remain caught in the middle, unable to
change. Motivational interviewing encourages
people to explore these mixed feelings, so
that they can move toward positive change.
• the counsellor does not try to convince the
person to change, but instead guides them to
reach conclusions themselves, and draws out
the internal motivations unique to the person.
• one of the most effective techniques in
doctor–patient interactions
Latchford G, Duff A. Motivational interviewing: a brief guide. Leeds: University of Leeds; 2010

50. Counselling for behaviour change
through brief interventions
• professional guidance and support to help a person to solve a
problem
• Counselling for healthy lifestyles involves guiding and supporting
patients toward making changes in certain behaviours to reduce
their risk
• a short interaction of 3 - 20 minutes between health worker and
patient.
• aims to identify a real or potential problem, provide information
about it and then motivate and assist the patient to do something
about it.
• how ? / what?

51. 5As
• a technique originally used in smoking cessation programmes
• represents a structured combination of motivational interviewing
and behavioural counselling
• a tool used for brief interventions. What a health worker can do to
help someone who is ready to change.
• SMART goals: specific, measurable, agreed, realistic, time-bound
• GPs are likely to achieve the first two steps of the 5As approach (ie
ask, assess), but may find it more challenging to deliver the
remaining three steps (ie advise, assist, arrange).

52. 5As

55. Trends in the Number of Obese Persons
N Engl J Med 2013;369:954-64

56. Diet Choice - determinants?
• Biological - hunger/ taste
• Economic - cost/ income
• Physical - access/ skills
• Social - class/ culture/ context
• Psychological - mood/ stress
• Attitudes/ Beliefs

58. Advice/ Provide written materials