Abstract
Over the past century, life expectancy has increased by approximately 8 years. Although this is a remarkable achievement, it is also a mixed blessing, and there is a distinct downside to this success, mainly the dramatic inversion of the population pyramid that is projected to take place in the not too distant future. The consequences of this evolution, together with the drop in the birth rate in Western societies, have major effects in terms of demographic changes.
The aging of the post-baby boom population means that there will not be enough young people to ensure the sustainability of the funding of healthcare and pension benefits for the elderly. This will have important socioeconomic consequences, which we are already starting to have to come to grips with in the Western world.
Furthermore, lifestyle, too, is undergoing sweeping changes. Major social milestones are being crossed increasingly later in life, such as getting married, starting a family and assuming greater work responsibilities. It is no longer possible to experience somebody's death at home and when this happens we are unprepared to cope with it.
Nevertheless, let's not be too pessimistic. We should praise where praise is due. Much to our pride, cardiologists take most of the credit for the extended life expectancy, as we contributed to at least 6 of the 8 years in the observed increase in life expectancy, while much less success has resulted from progress in other specialities.
Yet, although we as cardiologists may justifiably bask in our success, we should take care not to drop our guard. Cardiovascular disease (CVD) is expected to stay the number one killer in the western world for the next 20 years; we still have plenty of work ahead of us.
Our potential scope of action is enormous. We have already proven that we can treat and prevent CVD. Prevention is obviously much better than treatment. However, we have developed our profession mainly to treat and only recently have we started to pay attention to other aspects as well. It is important to remember that although treatment rests entirely in the hands of the cardiologists, prevention, quite rightly, does not and should not. The real question is who should deal with prevention: doctors, cities, nations, politicians, societies? To answer this question one has to ask what exactly is cardiovascular prevention. In CVD, the archenemy is atherosclerosis and its clinical manifestations such as angina pectoris, myocardial infarction, transient ischaemic attacks, ischaemic stroke, sudden death, etc. However, as the ultimate cause of atherosclerosis is still cloaked in mystery, all our attention is directed towards addressing modifiable risk factors such as smoking, sedentary behaviour, nutritional imbalance, impaired glucose tolerance and diabetes, hypertension, dyslipidemia, overweight and abdominal adiposity, heart rate, socioeconomic status, etc.
Clearly, all of this is too much and too important to be left in the hands of the cardiologists or of the general practitioner alone. First, because they simply do not have the time, and, second, because they do not have the know-how to deal with such a complex issue on their own.
It is all very well and easy to tell patients that they have to ‘change their lifestyle’ and draw up a list of dos and don'ts, of pleasures forbidden and burdens imposed. Taken to the extreme, the issue becomes a philosophical one, in the sense that if we are really in earnest about preventing CVD, the majority (if not all) aspects of western civilization will have to be altered dramatically.
Changing the lifestyle of a population for the better is no easy task – ironically, getting it to deteriorate is easily done: the negative influence of subliminal messages from consumer society (TV, movies, internet) is pervasive to the extent that even in Italy, children now prefer burgers and chips to the traditional plate of spaghetti with tomato and basil, which, of course, is the healthier option! Changing the lifestyle of a population means challenging important vested economic interests – such as the tobacco industry, to name but one. The introduction of legislation banning smoking in public places in Italy has been effective in reducing tobacco consumption, and good results in terms of reduction of CVD mortality are already noticeable at a national level [1].
This was one of the many reasons that stimulated us to make ‘Ferrara’, a small town of approximately 134 000 inhabitants, located in the county of Emilia Romagna in Italy, the city of prevention.
There were several reasons for making Ferrara the city of prevention in Italy. First, Ferrara is known as the city of bicycles. Being situated on a plain, the citizens of Ferrara traditionally use their bicycles to move around town. Second, Ferrara is surrounded by a medieval wall, approximately 9 km in circumference. On top of the wall there is an alley that makes it the ideal place to go for a walk, a run, to go by bike, or to exercise any other type of recreational activity. The city wall, or the so-called ‘mura’, has become a sort of meeting place for the citizens of Ferrara, where they go not only to exercise but also to meet their friends. Therefore, in Ferrara, at least, a small degree of exercise is a must!
Furthermore, from an economic point of view, Ferrara is completely dominated by the agriculture industry and Ferrara is famous all over Italy for its vegetable (mainly asparagus) and fruit production (pears in particular). Therefore, it is not difficult to obtain the recommended five portions of fruits and vegetables a day in Ferrara. Being situated close to the flood plain of the river Po, the biggest river in Italy, Ferrara is also famous for its fish industry and particularly for the so-called ‘bluefish’ which is very tasty, inexpensive and extremely rich in omega 3 which has been proven, once again by two Italian studies – the Gissi trials – to be effective in preventing myocardial infarction and also in reducing the progression of heart failure [2, 3]. Thanks to all of these characteristics Ferrara has the basis for being a city of prevention.
Several initiatives have been put into action to this end, some are still ongoing, and others are in the pipeline. This is indeed a joint effort of the entire city, of its municipality, university, Mayor, hospital, local province, supermarkets, banks and private industries, etc.
What have we achieved so far?
First of all, we launched an initiative called ‘Ferrara-Arte e Prevenzione’. Ferrara is also known for its art exhibitions shown in marvellous historic palaces, such as the Diamond Palace built in 1503 and the castle built in 1385. The castle has also become the official national site of the well-known Hermitage museum in St Petersburg. The province kindly provided the Chair of Cardiology of the University of Ferrara a room in the castle where doctors performed free-of-charge calculations of the risk chart of the 4208 visitors in a period of 2 months. The project was carried out in conjunction with the Istituto Superiore di Sanità, the Italian Health Ministry and the region Emilia Romagna.
Two types of risk charts were used. One, which is the official chart from the Italian Ministry of Health and of the ISS, the same one used for the project ‘Cuore’ [4], and one modified by the University of Ferrara which, in addition to the usual risk factors, also takes into consideration the heart rate, the abdominal circumference, the body weight and provides ideas of the degree of education and anamnestical data.
The same project and the same risk charts will be used in different types of population – for example, in housewives doing the grocery shopping at the supermarket, metal-mechanic industry workers and the approximately 2400 employees of the hospital of Ferrara. The idea is to compare the level of risk of all different population classes and to see whether education, socioeconomic background, awareness and knowledge affect the outcome. It will be interesting to see the data of the hospital employees!
In addition, there will be a horizontal continuation of the measurement of the risk chart of these individuals for the next 10 years to monitor their evolution in terms of prevention. For this purpose, the university has established a centre where all the citizens in Ferrara can go, have their risk chart calculated and find dedicated personnel able to provide proper recommendations and tools in terms of lifestyle and prevention. The centre is going to be built together with Gruppo Villa Maria (GVM) and will be equipped with a gymnasium and a kitchen to run professional courses on how to shop for preparing healthy recipes and to give a proper introduction to exercise.
In this way, we hope to encourage the population of Ferrara to decrease the consumption of saturated fats and equally importantly to increase the consumption of polyunsaturated fats, fish, fruit and vegetables and, of course, to reduce smoking. Counselling for this will also be provided at the centre.
As most of the CVD burden can be attributed to modifiable lifestyle and dietary risk factors [5–7], the Chair of Cardiology of the University of Ferrara together with the Italian Society and the Federation of Cardiology has published two cookery books, one for people with high cholesterol and one for those with diabetes and hypertension. The books consist of a simply written educational part as well as several recipes, all colourfully illustrated by attractive photographs. About 60 000 copies have been distributed free of charge to general practitioners, cardiologists, nurses and hospitals. The book can also be purchased at a reasonable price and of course will be available for consultation at the centre. Some of the recipes have also been adopted by the restaurants in Ferrara and are highlighted in their menus with a certification of ‘functional food’ by the Chair of Cardiology. The University is also working with Vassalli Bakering to produce a ‘Pane del Cuore’, which is a healthy white bread with no salt but rich in fibres and omega 3 fatty acids.
These books, however, are just some of the initiatives in Ferrara and there are many others in the pipeline not only focusing on the prevention of CVD but also on the prevention of disease in general, taking into account that smoking cessation, healthy diet and exercise are also important for pneumology, oncology, etc.
Will all of this be successful? It is too early to say. However, some data are already available. The population of Ferrara has the record on longevity in its country: Emilia Romagna – why? We believe that it through the ‘Ferraresi’ cycle, run on the mura, eating more fruits, vegetables and bluefish and being aware of CVD risk, we can bring in the difference. After all, prevention is awareness!