Trovato EPMA Journal 2012, 3:8

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REVIEW Open Access

Behavior, nutrition and lifestyle in a

comprehensive health and disease paradigm:
skills and knowledge for a predictive, preventive
and personalized medicine
Guglielmo M Trovato

Abstract
Health and disease of individuals and of populations are the result of three groups of risk factors: genetics,
environment and behavior. Assessment, interventions and tailored changes are possible with integrated
approaches more effective if respectful of individuals and different cultures. Assessment tools and integrated
interventional strategies are available, but widespread knowledge, skills and competence of well trained individual
Medical Doctors still lack. Mediterranean diet is an appropriate reference paradigm because encompasses
consistent research background, affordable sustainability, widespread comprehensibility and attractiveness inside a
cultural framework of competences and skills in which the Medical Doctors can personally manage the need of
prediction (early diagnosis), prevention (intervention on healthy persons) and tailored therapy and follow-up for
patients. This profile is flexible and adjustable according to specific needs and preferences due to different
economic and ethno-cultural milieus. It can enhanced through on-site/e-learning Continuous Medical Education
(CME), by training and using friendly and affordable equipments.
Keywords: Mediterranean diet, Physical exercise, Health psychology, E-learning, Medical ultrasound, Cluster of
medical skills

Introduction historical, with a strong psychological and sociological

Health and disease of individuals and of populations are basis. This is the reason that data on habits, attractiveness
the result of three groups of factors: genetics, environ- of diet, quality of food and alimentation are the more con-
ment and behavior. Only the last is mostly dependent sistent source of knowledge explored by epidemiological
by the chooses of the single person, but assessment, tools.
interventions and tailored changes are possible. A cultural framework of competences and skills by
Medical genetics and genetic variation studies relate to which Medical Doctors can personally manage the need
human health and disease: knowledge and skills in DNA of prediction (early diagnosis), prevention (intervention
sequencing and genomics make possible to study the on healthy persons) and tailored therapy and follow-up
molecular sequences associated with many human dis- for patients is the premise for reasonable guidelines
eases, to predict and council accordingly, to prevent and/ aimed at more effective clinical practice and favorable
or treat several conditions. Nutrigenomics is the study of cost-benefit balance. Despite the current perception of
the effects of foods and food constituents on gene expres- the usefulness of interventions, also at the clinical indivi-
sion, and has been associated with the idea of personalized dual level, on lifestyles, nutrition and physical activity,
nutrition based on genotype. Nonetheless the actual deter- and the bulk of studies available, an effective translational
minants of human diet are economic, climatic, geographic, practice from the EBM of the epidemiology to the EBM
of therapeutic interventions is limited if not totally lack-
Correspondence: [email protected] ing. Nutritional knowledge and skills teaching and train-
Department of Internal Medicine–Diagnostic and Therapeutical Unit, ing are a neglected subject of the Curricula of all Schools
University of Catania, Catania, Italy

© 2012 Trovato; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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of Medicine and of allied Health professions. Moreover, consequence of “contagious” behaviors. These condi-
we are far from the implementation of skills for enhan- tions imply loss of independence, years of disability, or
cing healthy lifestyles, including appropriate physical death, and impose a considerable economic burden on
activity prescribing. This is due to several factors and health services. However, despite the well known bene-
first of all to excessive focus and expectations related to fits of a healthy lifestyle, only part of adults follow
pharmaceutical approach and results. Moreover, to rely changes toward healthier lifestyles, and usually only for
to multiple specialty consultations and procedures for some of them; nonetheless, through other factors, also
reaching a diagnosis and for managing by follow-up pharmacological, prevalence is declining and develop-
patients is a major disadvantage in terms of time, finan- ment and consequence of unhealthy lifestyles delayed.
cial expenses and difficult clinical synthesis and decisions. This approach, i.e. tardy interventions, is certainly
The medical doctor can be trained not only, as cur- expensive, and not easily affordable by many societies
rently done, to become an improbable medical-financial and individuals. The challenge of promoting physical
manager but, as intuitive for anybody, to manage the activity is as much the responsibility of governments, as
psychological and nutritional assessment of patients, to of the people. However, individual action for physical
extend the power of physical examination by non-inva- activity is influenced by the environment, sports and
sive, quick and almost inexpensive non-invasive proce- recreational facilities, and national policy. It requires
dures (ECG, ultrasound), and to prescribe what needed, coordination among many sectors, such as health,
included drugs or other therapies within the scheme of sports, education and culture policy, media and informa-
a reasonable follow-up strategy. tion, transport and mobility development, urban plan-
ning, local governments, and financial and economic
Lifestyles planning.
Lifestyle is a term to describe the way individuals, family The combination of the main healthy lifestyle factors–
circles, and societies live and which behavior they mani- maintaining a healthy weight, exercising regularly, fol-
fest in coping with their physical, psychological, social, lowing a healthy diet, and not smoking–seem to be
and economic environments on a day-to-day basis. It is associated with as much as an 80% reduction in the risk
closely related with the concept of risk [1], with multiple of developing the most common and deadly chronic dis-
and complex interferences. Substantial proportions of eases. This reinforces the current public health recom-
global disease burden are attributable to major risks, to mendations for the observance of healthy lifestyle habits,
an extent greater than previously estimated. Developing and because the roots of these habits often originate
countries suffer most or all of the burden due to many during the formative stages of life, it is especially impor-
of the leading risks. Strategies that target these known tant to start early in teaching important lessons con-
risks can provide substantial and still underestimated cerning healthy living. The complex puzzle can appear
public-health gains. like a Arcimboldo’s drawing, in which many compo-
Lifestyle is expressed by daily work and leisure pro- nents are integrated into an unique figure (Figure 1).
files, including activities, attitudes, interests, opinions, The first recent evidence that lifestyle intervention are
values, and allocation of income [2]. From a psychologi- powerful and beneficial also on the actual levels of dis-
cal point of view lifestyle derives from people’s self ease biomarkers [3], including the traditional cardiac
image or self concept (the way they see themselves and risk factors and emerging biomarkers, is a further reason
believe they are seen by the others), including self- for following this way.
esteem and self-efficacy. Lifestyle is a composite of
motivations, needs, and wants and is influenced by fac- From the risk factors to the PPPM
tors such as culture, family, reference groups, and social The medical study of lifestyles, since the first ones of
class. more than 50 years ago [4,5] is actually coincident with
Lifestyle diseases are diseases that appear to increase and derived by the study of risk factors for several dis-
in frequency as countries become more industrialized ease [6,7]: the primary goals were using them as predic-
and people live longer. Lifestyle diseases share risk fac- tive tools, helpful for life insurances and for physicians
tors similar to prolonged exposure to three main modifi- and health institutions interested in prevention. The
able lifestyle behaviors–smoking, unhealthy diet subsequent approaches were aimed at the translation of
(including alcoholics abuse), and physical inactivity–and these information to clinical individual strategies.
result in the development of non-communicable and The advent of personalized medicine [8,9] as a medical
chronic diseases, substantially degenerative diseases model emphasizing the customization of healthcare, with
group (heart disease, stroke, diabetes, obesity, metabolic all decisions and practices being tailored to individual
syndrome, chronic obstructive pulmonary disease, and patients in whatever ways possible, is changing this sce-
some types of cancer), that can actually be considered nario. The current development of stratified medicine,
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Figure 1 Dietary/physical exercise Arcimboldo, which visually depicts guidelines and ideas is expressly designed by Giuliano
Cangiano, by courtesy. It represents the preferred food, according to current guidelines, from those to be most frequently chosen to those to
be exceptionally included. The Arcimboldo is running, obviously: practicing physical exercise.

i.e. the management of a group of patients with shared Medicine and human civilization, share the same his-
biological char-acteristics [10], is now possible and is tory of people aimed at an own personalized care, in
bringing a further advance to medicine. health and disease. The goals are to prevent pain and/or
Molecular diagnostic testing, molecular profiling tech- illnesses, to predict what could be beneficial and what
nologies, including proteomic profiling, metabolomic could be detrimental and to act appropriately with an
analysis, genetic testing and nutrigenomics, are begin- adequate attention to persons.
ning to be used to select the best therapy in order to The oldest approaches were based on observations and
achieve the best possible medical outcome for that per- experience but also economical, political and religious
son or group [11,12]. needs and beliefs were and are strongly operating [13].
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This “heritage”, the tradition of medicine, which had to adequate but currently widespread and up-to-date medi-
be adapted to different environment and, namely, cli- cal-scientific background, with the support of a knowledge
mate, is now preserved, modified or decidedly revolutio- networks also e-learning based, a substantially sustainable
nized by more scientific approaches [14]: these are approach to PPPM is possible everywhere.
currently included inside the definition of evidence-based It is noteworthy that greater epidemiological studies,
medicine (EBM). even attempting to focus at the effects of lifestyle
The steps of the recent history of predictive, preven- changes [15], are able to give quite generic information
tive and personalized medicine (PPPM) can be summar- based mostly on minor changes defined by averages that
ized as follows: become significant as a consequence of the numerous-
ness of the studied population and groups.
1) The definition of risk factors or determinants of
health and disease derived from extensive, prolonged Risk markers and indexes
and still now ongoing epidemiological studies (Fra- A risk marker, also called, specially as a group, risk index,
mingham, Seven Countries Studies and, thereafter, is a variable that is quantitatively associated with a dis-
many others, most recent and elsewhere) that dis- ease or other outcome. This is an epidemiological infor-
covered the most critical predictive indexes of mation, and means that direct alteration of the risk
disease. marker does not necessarily alter the risk of that disease
The corresponding side of this approach was and is or the probability of that outcome. A risk factor, not
the search for biological markers (genetic, bio- necessarily coincident with the risk marker, is a condition
chemical, derived by imaging procedures) to be that actually determines one or more diseases. The mod-
used individually or in more integrated algorithms. ern concept stems from the Framingham Heart Study
2) The preventive approach through population or [16]. This is a long-term (1948-), still now ongoing cardi-
worldwide interventions, and by smaller risk groups ovascular study on residents of the town of Framingham,
intervention, driven by institutional guidelines and Massachusetts. Among the identified risk factors some-
definite laws and rules. In this case the biomarkers one is a real disease, like diabetes and hypertension,
are used as monitoring tools. other are habits (smoking, sedentary life), other are more
3) The personalized approach is the clinical side of a markers, biochemical (cholesterol, triglycerides, uric
professionally EBM. It includes contributions from acid), or not (left ventricular hypertrophy by ECG, or
advanced molecular and imaging diagnostics, innova- atrial fibrillation) of a risk or of a disease, not the disease
tive histopathology definitions, and pharmacology. The or the risk itself. The outcomes of existing risk factors
neglected skills and competence are implicit and even includes primarily myocardial infarction, sudden death,
more valuable. They are in the domain of healthy life- congestive heart failure, cerebral stroke. The epidemiolo-
style, and encompass strategies for enhancing quality gical study in the subsequent generations of this Fra-
of nutritional profiles, physical activity patterns, and mingham population is gaining information on several
socio-environmental conditions. These last can be aspects, including diet and other habits [17]. The concept
positively modified also at the individual level (noise, of risk and causative factors for many disease, specially
neighbours, accessibility and even minor architectural lung and cancer disease, is inside the mind of people and
barriers). researchers, and the current state of the knowledge is
wide and complex.
The sustainability of this approach can appear doubtful,
if not impossible outside highly organized and advanced Social determinants of health
health Institutions. This is not true. The core subject of These are the economic and social conditions under which
our integrated clinical work (MD, psychologist, dietician people live which determine their health. They are “socie-
and sport and exercise medicine MD specialist), is devel- tal risk conditions”, rather than individual risk factors that
oped in our as in other Internal Medicine Unit along these either increase or decrease the risk for a disease [18,19].
lines, with easily affordable integrations when necessary. The prediction of adult incidence and death from disease
This methodology becomes affordable when a consistent is related to income differences which are also strongly
and reliable clustering of diagnostic skills is present in a related to the health of children and youth. Worldwide
circle of few specialists; they must be focused at the early children living in low-income families are more likely to
non-invasive diagnosis, to be refined with more advanced experience greater incidence of a variety of illnesses, hospi-
procedure when necessary, and at the appropriate and tal stays, accidental injuries, mental health problems, lower
timely accomplishment of pharmacological, nutritional, school achievement and early drop-out, family violence
behavioral and exercise therapeutic interventions. With an and child abuse, among others. Social determinants of
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health are blended throughout the life of individuals and activity in the prevention and treatment of disease has
populations to the more traditional and better studied risk been proven over recent years. Physical activity is essen-
factors. tial for improved health as well as for longevity [22].
The socioeconomic circumstances of individuals and Over recent years, ‘physical activity on prescription’
groups are equally or more important to health status has proven to be a feasible way to increase an indivi-
than medical care and personal health behaviors, such as dual’s or patient’s physical activity levels: It has been
smoking and eating patterns. But depend from complex suggested that leisure-time activity will be insufficient to
and not easily modifiable factors. Nonetheless, in the prevent increasing population levels of obesity and
mean-while, we cannot wait only a more global, world- chronic diseases, and it may be necessary to focus on
wide or national approach. We have the awareness that decreasing sitting and increasing activity in transport
financial and intellectual resources in any State or Nation and at work to restore the energy balance that resulted
are not always adequate for a timely and even depoliti- in a much-more-stable body weight [23,24].
cized approach. So, the search for appropriate strategies The promotion of physical activity is not only a matter
aimed at improving individual or group health and, if of health education and of health behavioral strategy but
possible, quality of life, is warranted. The awareness that is effective and feasible by the ‘physical activity on pre-
medical doctors, and all health professionals, with their scription’ as already in use in Denmark, Sweden [25],
advices, prescriptions and, why not, personal examples is New Zealand and in few Italian Regions [26].
important. This is the point from where it is possible to A reliable methodology of assessment of physical
move significant steps toward the understanding of the activity is a core point for any quantitative approach in
complex and a relevant component of an integrated epidemiology and clinics. One of them, used mainly as a
approach to the management of health determinants. support for nutritional assessment, is the Baecke Ques-
This is a core position of the strategy for working for tionnaire, that can be managed easily by doctors and
healthier persons and societies and a key step toward health professionals [27] assessing physical activity at
civilization. work, sport during leisure time and physical activity
The domino effect of the tenacious persistence of med- during leisure time excluding sport. The key recommen-
ical concepts and the individual effort of their application dation against sedentary habits can be summarized with
must be carefully considered and appropriately used. a pyramid, in which dietary advices are integrated with
This is confirmed by the interventional studies that chan- general physical exercise prescriptions (Figure 2).
ged incidence and prevalence of disease acting on one
particular strategy (smoking, alcohol, excessive fats in Nutritional profiles - guidelines
diets withdrawal). All these have specific and more gen- Diets and recommendations are continuously provided
eral effects, even when focused to small population also as official guidelines by numerous medical and gov-
group. Moreover, a lesson is that even interventions on ernmental institutions. The attempt and the perspective
single risk factors can have positive effects for other is the promotion of overall and/or of certain aspects of
apparently non related risk factors. Of course, neutral or health. Advances in the fields of molecular biology, bio-
somewhat unfavorable effects are possible, as in the case chemistry, and genetics enhanced the study of nutrition
of smoking withdrawal and body weight increase [20]: that is increasingly concerned with metabolism and
this information warrants a more integrated strategy, metabolic pathways: the sequences of biochemical steps
including pro-active nutritional and physical activity through which substances in living things change from
counseling. one form to another. The clinical experience and knowl-
edge are contributing to novel dietary recommendations
Sedentary lifestyle for the general population.
Sedentary lifestyle is a medical term used to denote a
type of lifestyle with no or irregular physical activity. Institutional driving of healthy diet
The negative connotation is a recent concept, that stems Particularly within the last years several government
from epidemiological as well from intervention studies agencies have attempted to combat the amount and
[21]. method of media coverage plentiful upon “junk” foods.
Sedentary activities include sitting, reading, watching Governments also put pressure on businesses to pro-
television and computer use for much of the day with lit- mote healthful food options, consider limiting the avail-
tle or no vigorous physical exercise. ability of junk food in state-run schools, and tax foods
Physical inactivity is linked to almost all common that are high in fat. Vending machines in particular
health problems including cardiovascular diseases, type have come under fire as being avenues of entry into
II diabetes, obesity/overweight, cancer, dementia and schools for junk food promoters. However, there is little
depression. Furthermore, the great value of physical in the way of regulation and it is difficult for most
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Figure 2 This pyramid is more focused to the physical activity suggestions merged using the current guidelines and our clinical
strategy. Physical activity is recommended with a daily exercise habit (10.000 steps, no elevators, no cars) and regular aerobic more intensive
physical exercise (3 times/week) according to specific needs and possibilities.

people to properly analyze the real merits of a company food can harm as a consequence of the unfavorable effects
referring to itself as “healthy.” There are different ways of its component. The key point is that any food product
to interpret the food-health relationship and make sense and its related claims should be placed in the context of
of the evidence about healthy eating in the everyday diets and analyzed from a bio-psychosocial standpoint.
experience. With this premise, the need of a persona- The communication of health benefits of one or most
lized health psychology approach is needed [28]. “functional food” to consumers is of critical importance
and the knowledge must be reliable and up-to-date in
Functional food order to allow informed choices about the foods to eat
There is since several years the scientific evidence that and enjoy [29].
some foods and food components have beneficial physio- Many “functional food” are key components of Medi-
logical and psychological effects over and above the pro- terranean diet, and, at least equally important, also the
vision of the basic nutrients. Moreover, the concept of cooking modalities are usually consistent with the need
“positive” or “optimal” nutrition, has its focus more to of preserving the physiologically effective components
the quality and adequacy of dietary patterns than to the [30]. This is not the minor reason for supporting a com-
strategy of eliminating or avoiding “dangerous” or prehensive approach warranting strategies for healthier
“unhealthy” food. Fruits, vegetables, legumes, olive oil, dietary profiles by easily and friendly concepts and
whole grains, wine and milk have been found to contain messages.
components with potential health benefits. On these There is widespread belief that organic food is signifi-
basis, new foods are being developed to enhance or cantly safer for consumption than food grown conven-
incorporate these components potentially beneficial for tionally. But this belief is not systematically based on
health through evidences derived from epidemiological, scientific evidence. Nonetheless, the awareness that foods
clinical and/or pathophysiological studies. claiming to be organic are free of artificial food additives,
In general, functional food are consumed as part of the and are often processed with fewer artificial methods,
normal diet and are considered useful and “functioning” materials and conditions, such as chemical ripening, food
because contain in significant quantity biologically active irradiation, and genetically modified ingredients is more
components which could enhance health or reduce risk of comfortable for most consumers. Pesticides are allowed
disease. Very similar, in concept, to drugs, it is reasonable so long as they are not synthetic. In this subset also bota-
to have in mind that excessive amount of a “functional” nically-derived insecticides have gained favor in recent
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years, due in part to the perception that, because they There is the need of an universal reference paradigm,
originate from plant material, they are more safe or “nat- easily understandable and communicable, sustainable
ural” [31,32]. These pesticides are often used for growing and with a consistent scientific support, sufficiently
crops organically, according to guidelines set forth by comprehensive and attractive in different countries and
certification programs, and may also find favor in organic population, to be promoted in a globalized society, such
food production, both in the field and in controlled the world is now.
environments. Valuable contributions to domestic food
production are present in countries where strict enforce- Mediterranean diet as an unifying reference
ment of pesticide regulations is impractical. paradigm for healthy lifestyles
The history of Mediterranean diet is the same history of
Translational research and medicine culture, populations and economies of the Mediterranean
Evidence-based medicine (EBM) or evidence-based prac- area: by this approach it is very easy to misunderstand its
tice (EBP) applies the best available evidence gained meaning. In the Old Greek Medicine, and it means also
from the scientific method to clinical decision making Magna Graecia and Sicily, of course, a profile of healthy
[33]. It assesses the strength of evidence of the risks and diet was already present, and was very similar to that one
benefits of treatments (including lack of treatment) and that we consider now “Mediterranean”.
of diagnostic tests. Translational medicine, as most The “discovery” of the benefits of Mediterranean diet
EBM, is a medical practice based on interventional epi- by the Rockefeller Foundation Missions and by Ancel
demiology. It is a natural progression from EBM. It inte- Keys during and immediately after the Second world war
grates research from the basic sciences, social sciences was the natural consequence of the widespread but vague
and political sciences with the aim of optimizing patient ideas asserting that Mediterranean food and culinary tra-
care and preventive measures which may extend beyond ditions were beneficial to health. The Seven Countries
healthcare services. It implies the process of turning Study is the first study that systematically examined the
appropriate biological discoveries into drugs and medi- relationships between lifestyle, diet, coronary heart dis-
cal devices that can be used in the treatment of patients. ease and stroke in different populations and in different
Translational research is a paradigm for research alter- regions of the world. It directed attention to the causes of
native to the dichotomy of basic research and applied coronary heart disease and stroke, but also showed that
research [34]. It is often applied in the domain of medi- an individual’s risk can be changed [35]. The Seven
cine but has more general applicability as a distinct Countries Study showed that increased cholesterol
research approach. It is also allied in practice with the (hypercholesterolemia) increases cardiovascular risk both
approaches of participative science and participatory at the population level and at the individual level. It
action research. As a general concept, it is a cross disci- demonstrated that the association between increased
plinary scientific research that is motivated by the need cholesterol and coronary heart disease (CHD) is homoge-
for practical applications that help people. So, the pri- neous across different cultures. In addition, in the sub-
mary goal of “translational” research is to integrate group of participants who suffered from cancer, the
advancements in molecular biology with clinical trials, study revealed that increased cholesterol and being over-
taking research from the “bench-to-bedside”. weight or obese increases mortality from cancer.
Continuous improvements of community-based The conceptualization of what more exactly is meant by
approaches, and also effective and sustainable approaches «Mediterranean diet» today, and its benefits, was per-
for prevention become possible with the epidemiological formed, amongst others, by Walter Willett, Harvard Uni-
and biological premise to translation of researches into versity. Since then contribution from several parts of the
interventions. Considering health determinants and risk USA, Europe and mainly from Greece, Italy and Spain
factors, this needs an integrated view of educational and gave a further progress to knowledge. For instance, Medi-
environmental actions to facilitate greater physical activ- terranean diet, articulated into extensive lifestyles inter-
ity, together with fiscal and regulatory changes to pro- ventions in a clinical follow-up study, improves renal
mote production, promotion, and delivery of healthier artery circulation, decreasing renal resistive index, even
meals and total food supply. without significant modifications of insulin resistance.
Practitioners of any health profession, scientists, econo- This is a beneficial effect and modifies the pathophysiology
mists and food producers and suppliers, media responsi- of essential hypertension [36]. The effects on autonomic
ble persons, policy makers, and the public need sound nervous system [37] and on oxidizing processes [38] can
evidence from these different and new research methods. be the key factors in the prevention of cardiovascular dis-
These approaches involve both experimental and non- ease. Also elderly cognitive impairment and Alzheimer
experimental methodologies, but are also sensitive to cul- disease are conditions associated with a very lower preva-
tural and ethnic priorities. lence in subject on Mediterranean diet [39].
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The pyramid of mediterranean diet based on a validated food-frequency questionnaire. We ask

According to the Harvard-led group a dietary pyramid all participants to report their weekly average intake of sev-
(Figure 3) has been developed to describe the Mediterra- eral food items that they consumed during the last week,
nean dietary pattern. This pattern consist of: 1) daily and then trying to extrapolate the average consumption
consumption of nonrefined cereals and products (e.g., during the last year. The frequency of consumption is
whole-grain bread, pasta, brown rice, and the like), fruits quantified in terms of the number of times a week each
(4 to 6 servings/day), vegetables (2 to 3 servings/day), food group was consumed. Thus a value of 0 was assigned
olive oil (as the main added lipid), and non-fat or low- to Mediterranean food items (see below) rarely or never
fat dairy products (1 to 2 servings/day); 2) weekly con- consumed. Alcohol consumption is measured in wine
sumption of fish, poultry, potatoes, olives, pulses, and glasses (100 ml) and quantified by ethanol intake (g/drink).
nuts (4 to 6 servings/week), as well as more rarely eggs One wine glass is equal to 12 g ethanol concentration.
and sweets (1 to 3 servings/week), and monthly con- According to the previous dietary pattern and the
sumption of red meat and meat products (4 to 5 ser- reported weekly frequency consumption of these food
vings/month). groups, we calculate each participant’s diet score, which
It is also characterized by moderate consumption of assessed adherence to the Mediterranean diet (range 0
wine (1 to 2 wine glasses/day), moderate consumption to 55).
of fat, and a high monounsaturated to saturated fat For alcohol the daily base is used, and the greater
ratio. daily use in the past week is used for scoring. We assign
The evaluation of the nutritional habits that we currently a score of 5 for consumption of 0-2 red wine glasses/
use since 15 years in our Medical Unit according and day for men, 1 red wine glasses/day for women, and
updated to Italian Nutritional Guidelines (Dietosystem®) is negative (unfavourable) scores for greater consumption

Figure 3 This pyramid represents both the nutritional and the physical activity suggestions merged using the current guidelines and
our clinical strategy. According to the Harvard-led group a dietary pyramid has been developed to describe the Mediterranean dietary pattern.
This pattern consist of: 1) daily consumption of nonrefined cereals and products (e.g., whole-grain bread, pasta, brown rice, and the like), fruits (4
to 6 servings/day), vegetables (2 to 3 servings/day), olive oil (as the main added lipid), and non-fat or low-fat dairy products (1 to 2 servings/
day); 2) weekly consumption of fish, poultry, potatoes, olives, pulses, and nuts (4 to 6 servings/week), as well as more rarely eggs and sweets (1
to 3 servings/week), and monthly consumption of red meat and meat products (4 to 5 servings/month). It is also characterized by moderate
consumption of wine (1 to 2 wine glasses/day), moderate consumption of fat, and a high monounsaturated to saturated fat ratio. The quality of
food is characterized by three main features: 1) short trade chain; 2) certified quality and 3) preference to the use of season’s food, particularly
fruits and vegetables.
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of more than 2 red wine glasses/day (1 for women). contributions that appear particularly effective because
Other alcoholics use is calculated as a negative value, are based on friendly intervention strategies. The same
according to alcohol grams: for 0-10 the score is 0, 10- efforts and interventions are not easily recognizable in
20 the score is -1, more than 50 g/day the score is -5 Europe, even with many limited national and suprana-
(see below). tional interventions.
Higher values of this diet score indicate greater adher-
ence to the Mediterranean diet, whereas lower values Mediterranean diet: food, recipes and cooking
indicate adherence to the “Westernized” diet. We Mediterranean diet and clinical nutrition are both
recently reported our experience on Mediterranean diet neglected tools that are useful in the prevention and
score (range 0-55). treatment of cardiovascular diseases. Web- and e-learn-
Mediterranean food (pasta and rice; whole-grain bread, ing course on life-style and Mediterranean diet are,
brown rice, legumes; fruit; green vegetables; fish, poultry; hopefully, a step toward a greater dissemination of these
nonfat or low-fat dairy products; olive oil) had assigned a information.
score of 0: no consumption, a score of 1 for 1 to 4 times/ Examples and modern culinary strategies in agreement
w, 2 for 5 to 8 times/w, 3 for 9 to 11 times/w, 4 for 12 to with Mediterranean diet “best practice” are available:
14 times/w, and 5 for more than 14 times/w; for wester- cookery books, web and video recipes, and also institu-
nized food (red meat; dairy products-butter; potatoes and tional, academic courses. Videos are available on the
eggs; cakes) opposite scores were assigned (i.e., 0 when a web, but actually the daily work done by dieticians with
participant reported more than 5 weekly consumption to: patients, their relatives and friends using also telephone
5 for no weekly consumption, score 4 for 1 weekly con- and social network empowering systems (mainly face-
sumption, 3 for 2 weekly consumption, 2 for 4 weekly book and, for individual empowering, skype and several
consumption, 1 for 5 weekly consumption); wine and windows/Mac applications, also for tablets and smart-
alcoholics (0-10 g of alcoholics from red wine for women phones) are innovative important instrument.
score 5; 0-20 g of alcoholics from red wine for men score The paradigm of Mediterranean diet, among other
5; each increment of 10 determines negative scores (20- confusing and not EBM based schemes and profiles, is a
30 = -1. 30-40 = -2. 40-50 = -3. 50-60 = -4, >60 = -5 for clear message addressing choice of food, balance, cook-
men; 10 less for women and for all non-wine alcoholics,: ing skills that is connected and articulated with related
10-2 = 0-1; 20-30 = -2; 30-40 = -3; 40-50 = -4; >50 = -5). lifestyles–physical activity and daily rhythms counseling.
A tentative, arbitrary cut-off for sufficient adherence to It can be optimally tailored if the medical doctors have
Mediterranean diet can be defined as a score >35. the competences to address their own prescription or,
Mediterranean score was assessed in 8138 healthy better, the integrated strategies of dieticians and psy-
non-diabetic, overweight/obese subjects,1996-2010, chologists trained for managing alimentary behavior.
referred for US liver diagnostic and dietary counseling. There is the confirm, from the intentional modification
In this population there is a trend throughout the last of dietary profiles assessed by the Alternative Healthy
15 years toward the loss of the adherence to Mediterra- Eating Index (AHEI) in the Whitehall II cohort [40], that
nean diet from 37.06± 3.213 to 34.82 ± 5.014 p < changes toward patterns with higher nuts and soy, total
0,0001, not associated with BMI or physical activity fiber, and, to a lesser extent, ratio of white to red meat
change (Figure 4). were associated with a decreased risk of mortality inde-
This information, that can be also interpreted as the pendent of other components. These findings, based on a
loss of adherence to the most internationally recognized 18 years lasting study, are consistent with those of several
guidelines for healthy nutrition, reinforces reasons and studies that have investigated other diet-quality scores
need for coordinated and sustainable interventions. and mortality; these studies support an inverse associa-
There are different possibilities of adapting the main tion between Mediterranean diet score and all-cause,
lines of the EBM nutritional recommendation to actual CHD, and cancer mortality. Mediterranean diet score,
individual and population conditions. Cultural and tradi- which measures adherence to a traditional Mediterranean
tional habits, gender, age, climate, financial and market- type of diet characterized by high intake of fruit, vegeta-
ing affordability are all conditions that can be optimally bles, cereal, potatoes, and fish; high ratio of polyunsatu-
managed, using appropriate skills and knowledge along rated fatty acids to saturated fatty acids; low intake of
adequate software applications, that can be tailored meat (white and red) and dairy products; and moderate
inside the frame of the current healthy nutrition and alcohol consumption. A protective effect of moderate
lifestyle guidelines. alcohol consumption on all-cause and CVD PMA Journal
Non-profit organizations, and particularly Oldways, in mortality, independent of other AHEI components was
USA, along Federal actions (Let’s move program and also shown. The putative mechanisms are complex, but
others) gave and are giving significant practical mainly include a reduced pro-inflammatory effect of
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Figure 4 Mediterranean diet score adherence and mortality. Mortality and diseases increase along the decrease of the adherence to a
Mediterranean diet profile, which is assumed as a proxy to the current European and North American lifestyle-nutritional guidelines.

Mediterranean diet (Figure 5) in comparison with a be important to consider multiple health indices when
strong unfavorable effect of western diets (Figure 6). identifying high risk groups [48].
The Whitehall study is the first to provide epidemiolo-
gic evidence that enhancing adherence to dietary recom- The cluster of clinical skills
mendations of the AHEI may decrease the long-term The opportunity of a more widespread cluster of clinical
risk of all-cause and CVD mortality. The WHEL study, skills inside small group of clinical practice is usually
in San Diego, demonstrated the same favorable effects recognized, but not demonstrated and even studied, and
of reverting to healthier profiles–diet and physical activ- is currently considered a strategy timely and responsive
ity–on breast cancer recurrences and prognosis [40]. to the needs of patients. It should be a shortcut toward
Similar trends are observed in the Eastern Hemisphere, effectiveness and a sustainable cost-benefit balance, in
in Japan [21] and the need of an integrated approach is the era of healthcare cost restraint. This approach should
warranted [41]. Even in our country, Italy, Adherence to include guidelines and expert recommendations for di-
nutritional guidelines, and, notably, to Mediterranean agnostic assessment and follow-up activities. An enor-
diet, shows a continuous decline in the past 15 years mous library of textbooks, manuals, scientific articles is,
(Figure 7). obviously, available. The need of a conceptualization of
This is the reason that in several countries, including the essential issues that can drive the PPPM approach of
USA, Mediterranean diet that encompasses advices for any medical doctor is strongly and widely perceived.
physical activity and moderate alcohol (wine) habits, is Clinical nutrition and dietary intervention are
proposed as a simplified but strong paradigm of healthy neglected aspects of the clinical prescriptions. Knowl-
lifestyle, coincident with the contemporary guidelines edge and skills background on medical doctors and
[42-44], strategically useful for promoting PPPM. In this health professionals is limited and capability of explicit
dietary context, the use of coffee is of benefit for arterial and protracted interventions are substantially inexistent.
hypertension through some renal mechanism [45,46] and Despite the efforts to improve quality of medical cur-
for fatty liver through the increase of insulin sensitivity ricula, it is still necessary an enhancement of knowledge
[47]. Multiple lifestyle behaviors have effects on health and training for undergraduate and postgraduates medi-
risks like obesity and other health outcomes. In order to cal students. This intervention will benefit from manda-
develop effective primary prevention strategies, it would tory CME course for medical doctors and professionals
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Figure 5 Anti-inflammatory mechanisms of Mediterranean diet are presented according to EBM studies. Nutrients’ profile of
Mediterranean diet, and of the present Italian and USA guidelines is associated with lower inflammatory action and lower oxidative stress of its
components. These are the two main features of Mediterranean diet composition which explain the lower prevalence of related disease
(rheumatic, allergic, degenerative including atherosclerosis, neurological, metabolic, cancer) in clinical and epidemiological studies. Greater
adherence to Mediterranean diet profile is associated with lower prevalence and severity of these conditions.

Figure 6 Pro-inflammatory mechanisms of Western diet are presented according to EBM studies. Nutrients’ profile of western diet is
associated with greater inflammatory action and greater oxidative stress of its components. These explain the greater prevalence of related
disease (rheumatic, allergic, degenerative including atherosclerosis, neurological, metabolic, cancer) in clinical and epidemiological studies. Lower
adherence to Mediterranean diet profile is associated with greater prevalence and severity of these conditions.
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Figure 7 Adherence to nutritional guidelines shows a continuous decline in the past 15 years. This is our experience on Mediterranean
diet score (range 0-55). It was assessed in 8138 healthy non-diabetic, overweight/obese subjects, 1996-2010, referred for US liver diagnostic and
dietary counseling. In our population there is a trend throughout the last 15 years toward the loss of the adherence to Mediterranean diet from
37.06 ± 3.213 to 34.82 ± 5.014 p < 0,0001, not associated with BMI or physical activity change. This information, that can be also more generally
interpreted as the loss of adherence to the most internationally recognized guidelines for healthy nutrition, reinforces reasons and need for
coordinated and sustainable interventions.

(including psychologists) and the assessment of the out- meaning and the power of laboratory information cannot
come (change of clinical approach with patients). In be disregarded: nonetheless, different and recent
health systems mainly funded by the States (public) this approaches are putting into evidence new and unex-
intervention is possible and suitable of analysis of the pected biomarkers of obesity, that, conceivably, are also
outcomes, in terms of benefit for several health indexes infectious causative factors [52,53]. The integration of
and of pharmaceutical and diagnostic procedures resolute intervention on lifestyles (nutrition, exercise,
expenses. habits) by psychological behavioral approach with expert
Nutritional guidelines and risk factor assessment skills and sustainable instrumental tools of assessment and fol-
and awareness are the necessary premise for a predictive low-up give a substantial and cost-benefit valuable con-
approach to tailored prevention and personalized medi- tribution. This is particularly important for diseases and
cine (the clinical perspective of medical doctors, alone or conditions in which most research and effort are in the
in small associated teams). This mechanism can work domain of pharmacology and multi-specialist diagnostic
and is largely sustainable and affordable for European assessment and follow-up [54,55].
Health and university systems (Figure 8). A renewed and The background and current state of the knowledge
greater appreciation of the traditional medical skills warrant strongly a wider use at the bedside, in emergency
(medical history and physical examination) focused to and in the general practice of medical ultrasound diagnos-
cardiovascular and respiratory disease, cancer, liver and tics, abdominal, cardiac, vascular and of the thyroid-neck
GI disease, disability (neurological, psychiatric, orthope- area. This is a true evidence-based challenge against the
dic & rheumatic disease) with a timely extension of the excessive expenses deriving from delay and uncertainty in
diagnostic skills with the current friendly and affordable diagnostics, involving often different specialists and in dif-
non-invasive procedures will succeed if an appropriate ferent places, with deplorable waiting lists.
cultural milieu, also through media actions, will be build- The expert recommendations to solve the problem
up and maintained. The easy identification and scoring of include dissemination, educational and research strategies
fatty liver and of liver fibrosis is the single direct morpho- and, principally, to build-up clinical excellence of younger
logical clue to the identification of a metabolic-nutri- doctors. The cluster of professional and expert skills, at
tional disease (even in the absence of obesity) and of the individual and group level is focused to predictive
consistent cardiovascular and renal risks [49-51]. The medicine (nutritional and physical activity assessment) and
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conditions (fatty liver and thyroid disease) is possible if

multi-expertise of the single medical doctor is available.
Tailored, personalized medicine is possible if it is easily
available a tailored and timely diagnosis and nutritional
profile assessment. This will allow affordable strategies for
a widespread appropriate medical prescribing of nutrition
and lifestyle change, with friendly and sustainable moni-
toring strategies. The place of a behavioral health psychol-
ogy approach is central in this strategy. The assessment of
illness perception and the enhancement of motivation and
self-efficacy, some of the psychological markers of compli-
ance and likely success of prescriptions, are the necessary
premises for reaching adherence to lifestyle changes
[56-58]. The role of the dietitian and of the physical activ-
ity counselor and instructor must share skills and compe-
tence of psychological feature: equally, medical doctors
can obtain adequate compliance to medical prescription
by appropriate approaches.

Conclusion
Outlook
Implementation of widespread friendly and non-invasive
diagnostic procedures will be effective and reasonably
with a favorable cost-benefit ratio if a consistent and dif-
fuse professional enhancement of skills in health psy-
chology, nutritional and physical activity assessment and
prescribing will be available. A reference paradigm of a
PPPM approach is possible inside a cultural framework
of competences and skills in which the Medical Doctors
can personally manage the need of prediction (early
diagnosis), prevention (intervention on healthy persons)
and tailored therapy and follow-up for patients. Overall
this profile, flexible and adjustable according to specific
needs and preferences due to different economic and
ethno-cultural milieus, can be warranted as an operative
Figure 8 Cluster of skills and knowledge for boosting a paradigm.
sustainable and effective PPPM. Knowledge and skills in health
psychology, nutritional and physical activity assessment and
prescribing can be enhanced through appropriate funding of Recommendation
Continuous Medical Education (CME), also by professionally targeted Knowledge and skills in health psychology, nutritional
e-learning. Professional post-graduate training and facilitation for and physical activity assessment and prescribing can be
purchasing friendly and affordable equipment facilities, mostly along enhanced through appropriate funding of Continuous
a professionally driven expertise in US non-invasive procedures, is
the other fundamental tool for enhancing an effective bedside
Medical Education (CME), also by professionally tar-
PPPM. geted e-learning. Professional post-graduate training and
facilitation for purchasing friendly and affordable equip-
ment facilities, mostly along a professionally driven
a friendly imaging of the most common and also rare dis- expertise in US non-invasive procedures, is the other
ease. The preventive actions will include interventions on fundamental tool for enhancing an effective bedside
nutrition-friendly schools (according to food and nutrition PPPM.
action plans in the European Region and to the nutrition
policy database for the WHO European Region) aimed at
preventing micronutrient deficiencies and at the childhood Acknowledgements
The lasting collaboration with Prof. Daniela Catalano is the basis of the
obesity surveillance, monitoring the progress of improve- clinical experience that made possible this review. Among all the medical
ments in nutrition, physical activity and reduction of obe- team of this Unit, the contribution of Dr. G.F. Martines is particularly
sity. Timely information on the most likely associated valuable; he provided also a significant help for graphical arrangement of
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most figures. Giuliano Cangiano is the Artist of the Dietary/Physical exercise College of Sports Medicine position stand. Exercise and physical activity
Arcimboldo, which visually depicts guidelines and ideas. for older adults. Med Sci Sports Exerc 2009, 41:1510-30.
25. Sørensen J, Sørensen JB, Skovgaard T, Bredahl T, Puggaard L: Exercise on
Received: 24 December 2011 Accepted: 10 February 2012 prescription: changes in physical activity and health-related quality of
Published: 22 March 2012 life in five Danish programmes. Eur J Public Health 2011, 21:56-62.
26. Giannuzzi P, Temporelli PL, Marchioli R, Maggioni AP, Balestroni G, Ceci V,
References et al: GOSPEL Investigators. Global secondary prevention strategies to
1. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ, Comparative limit event recurrence after myocardial infarction: results of the GOSPEL
Risk Assessment Collaborating Group: Selected major risk factors and study, a multicenter, randomized controlled trial from the Italian Cardiac
global and regional burden of disease. Lancet 2002, 360:1347-60. Rehabilitation Network. Arch Intern Med 2008, 168:2194-204.
2. Pomerleau O, Bass F, Crown V: Role of behavior modification in 27. Baecke JA, Burema J, Frijters JE: A short questionnaire for the
preventive medicine. N Engl J Med 1975, 292:1277-82. measurement of habitual physical activity in epidemiological studies.
3. Chainani-Wu N, Weidner G, Purnell DM, Frenda S, Merritt-Worden T, Am J Clin Nutr 1982, 36:936-42.
Pischke C, et al: Changes in emerging cardiac biomarkers after an 28. Widome R, Neumark-Sztainer D, Hannan PJ, Haines J, Story M: Eating when
intensive lifestyle intervention. Am J Cardiol 2011, 108:498-507. there is not enough to eat: eating behaviors and perceptions of food
4. Walker ARP: Can expectation of life in western populations be increased among food-insecure youths. Am J Public Health 2009, 99:822-8.
by changes in diet and manner of life? S Afr Med J 1968, 42:144-50. 29. Mariotti F, Kalonji E, Huneau JF, Margaritis I: Potential pitfalls of health
5. Morris JN, Crawford MD: Coronary heart disease and physical activity of claims from a public health nutrition perspective. Nutr Rev 2010,
work: evidence of a national necropsy survey. Br Med J 1958, 2:1485-96. 68:624-38.
6. George SJ: Lecture Lyman Duff Memorial. Lifestyles, major risk factors, 30. Ortega RM: Importance of functional foods in the Mediterranean diet.
proof and public policy. Circulation 1978, 58:3-19. Public Health Nutr 2006, 9(8A):1136-40.
7. Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes J: Factors of risk in 31. Isman MB: Botanical insecticides: for richer, for poorer. Pest Manag Sci
the development of coronary heart disease-six year follow-up 2008, 64:8-11.
experience. The Framingham Study. Ann Intern Med 1961, 55:33-50. 32. Isman MB: Botanical insecticides, deterrents, and repellents in modern
8. Gibson WM: Can personalized medicine survive? Can Fam Physician 1971, agriculture and an increasingly regulated world. Annu Rev Entomol 2006,
17:29-88. 51:45-66.
9. Hoggatt J: Personalized medicine-trends in molecular diagnostics: 33. Kosimbei G, Hanson K, English M: Do clinical guidelines reduce clinician
exponential growth expected in the next 10 years. Mol Diagn Ther 2011, dependent costs? Health Res Policy Syst 2011, 9:24.
15:53-5. 34. Terzic A, Waldman SA: Translational medicine: path to personalized and
10. Trusheim MR, Berndt ER, Douglas FL: Stratified medicine: strategic and public health. Biomark Med 2010, 4:787-90.
economic implications of combining drugs and clinical biomarkers. Nat 35. Menotti A, Lanti M, Kromhout D, Blackburn H, Nissinen A, Dontas A, et al:
Rev Drug Discov 2007, 6:287-93. Forty-year coronary mortality trends and changes in major risk factors in
11. Wang TJ, Gona P, Larson MG, Tofler GH, Levy D, Newton-Cheh C, et al: the first 10 years of follow-up in the seven countries study. Eur J
Multiple biomarkers for the prediction of first major cardiovascular Epidemiol 2007, 22:747-54.
events and death. N Engl J Med 2006, 355:2631-9. 36. Trovato GM, Pirri C, Martines GF, Tonzuso A, Trovato F, Catalano D: Lifestyle
12. Manolio TA: Genomewide association studies and assessment of the risk interventions, insulin resistance, and renal artery stiffness in essential
of disease. N Engl J Med 2010, 363:166-76. hypertension. Clin Exp Hypertens 2010, 32:262-9.
13. Rotimi CN, Jorde LB: Ancestry and disease in the age of genomic 37. Dai J, Lampert R, Wilson PW, Goldberg J, Ziegler TR, Vaccarino V:
medicine. N Engl J Med 2010, 363:1551-8. Mediterranean dietary pattern is associated with improved cardiac
14. Evidence-Based Medicine Working Group: Evidence-based medicine. A autonomic function among middle-aged men: a twin study. Circ
new approach to teaching the practice of medicine. JAMA 1992, Cardiovasc Qual Outcomes 2010, 3:366-73.
268:2420-5. 38. Dai J, Jones DP, Goldberg J, Ziegler TR, Bostick RM, Wilson PW, et al:
15. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB: Changes in diet and Association between adherence to the Mediterranean diet and oxidative
lifestyle and long-term weight gain in women and men. N Engl J Med stress. Am J Clin Nutr 2008, 88:1364-70.
2011, 364:2392-404. 39. Scarmeas N, Luchsinger JA, Stern Y, Gu Y, He J, DeCarli C, et al:
16. Dawber TR, Meadors M, Moore Fe JR: Epidemiological approaches to Mediterranean diet and magnetic resonance imaging-assessed
heart disease: the Framingham Study. Am J Public Health Nations Health cerebrovascular disease. Ann Neurol 2011, 69:257-68.
1951, 41:279-81. 40. Akbaraly TN, Ferrie JE, Berr C, Brunner EJ, Head J, Marmot MG, et al:
17. Pencina MJ, D’Agostino RB Sr, Larson MG, Massaro JM, Vasan RS: Predicting Alternative Healthy Eating Index and mortality over 18 y of follow-up:
the 30-year risk of cardiovascular disease: the Framingham heart study. results from the Whitehall II cohort. Am J Clin Nutr 2011, 94:247-53.
Circulation 2009, 119:3078-84. 41. Iso H: A Japanese health success story: trends in cardiovascular diseases,
18. Wanless D, Mitchell BA, Wister AV: Social determinants of health for older their risk factors, and the contribution of public health and personalized
women in Canada: does rural-urban residency matter? Can J Aging 2010, approaches. EPMA J 2011, 2:49-57.
29:233-47. 42. Golubnitschaja O: Promoting predictive, preventive and personalized
19. Marmot MG, Bell RG: Improving health: social determinants and personal medicine in global scale. EPMA J 2010, 1:523-4.
choice. Am J Prev Med 2011, 40(1 Suppl 1):S73-7. 43. Chandran U, Bandera EV, Williams-King MG, Sima C, Bayuga S, Pulick K, et al:
20. Flegal KM, Troiano RP, Pamuk ER, Kuczmarski RJ, Campbell SM: The Adherence to the dietary guidelines for Americans and endometrial
influence of smoking cessation on the prevalence of overweight in the cancer risk. Cancer Causes Control 2010, 21:1895-904.
United States. N Engl J Med 1995, 333:1165-70. 44. Bédard A, Goulet J, Riverin M, Lamarche B, Lemieux S: Effects of a dietary
21. Bertram LA, Stefanick ML, Saquib N, Natarajan L, Patterson RE, Bardwell W, intervention promoting the adoption of a Mediterranean food pattern
et al: Physical activity, additional breast cancer events, and mortality on fast-food consumption among healthy French-Canadian women. Br J
among early-stage breast cancer survivors: findings from the WHEL Nutr 2010, 104:1662-5.
Study. Cancer Causes Control 2011, 22:427-35. 45. Trovato GM, Pirri C, Martines GF, Trovato F, Catalano D: Coffee, nutritional
22. Tremblay MS, Warburton DE, Janssen I, Paterson DH, Latimer AE, Rhodes RE, status, and renal artery resistive index. Ren Fail 2010, 32:1137-47.
et al: New Canadian physical activity guidelines. Appl Physiol Nutr Metab 46. Catalano D, Trovato GM, Spadaro D, Martines GF, Garufi G, Tonzuso A, et al:
2011, 36(36-46):47-58. Insulin resistance in postmenopausal women: concurrent effects of
23. Murphy MH, McNeilly AM, Murtagh EM: Session 1: public health nutrition: hormone replacement therapy and coffee. Climacteric 2008, 11:373-82.
physical activity prescription for public health. Proc Nutr Soc 2010, 47. Catalano D, Martines GF, Tonzuso A, Pirri C, Trovato FM, Trovato GM:
69(1):178-84. Protective role of coffee in non-alcoholic fatty liver disease (NAFLD). Dig
24. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, Dis Sci 2010, 55:3200-6.
Fiatarone Singh MA, Minson CT, Nigg CR, Salem GJ, Skinner JS: American
Trovato EPMA Journal 2012, 3:8 Page 15 of 15
http://www.epmajournal.com/content/3/1/8

48. Ottevaere C, Huybrechts I, Benser J, De Bourdeaudhuij I, Cuenca-Garcia M,

Dallongeville J, et al: Clustering patterns of physical activity, sedentary
and dietary behavior among European adolescents: the HELENA study.
BMC Public Health 2011, 11:328.
49. Catalano D, Trovato GM, Martines GF, Pirri C, Trovato FM: Renal function
and severity of bright liver. Relationship with insulin resistance,
intrarenal resistive index, and glomerular filtration rate. Hepatol Int 2011,
5:822-9.
50. Trovato GM, Pace P, Tamburino C, Garufi G, Martines GF, Pirri C, et al:
Elective coronary stent patients: preinterventional functional status and
clinical-instrumental assessment. Heart Vessels 2010, 25:82-6.
51. Assy N, Djibre A, Farah R, Grosovski M, Marmor A: Presence of coronary
plaques in patients with nonalcoholic fatty liver disease. Radiology 2010,
254:393-400.
52. Trovato GM, Martines GF, Garozzo A, Tonzuso A, Timpanaro R, Pirri C, et al:
Ad36 adipogenic adenovirus in human non-alcoholic fatty liver disease.
Liver Int 2010, 30:184-90.
53. Trovato GM, Castro A, Tonzuso A, Garozzo A, Martines GF, Pirri C, et al:
Human obesity relationship with Ad36 adenovirus and insulin
resistance. Int J Obes (Lond) 2009, 33:1402-9.
54. Catalano D, Trovato GM, Martines GF, Randazzo M, Tonzuso A: Bright liver,
body composition and insulin resistance changes with nutritional
intervention: a follow-up study. Liver Int 2008, 28:1280-7.
55. Trovato GM, Martines GF, Trovato FM, Pirri C, Pace P, Garozzo A, et al:
Adenovirus-36 seropositivity enhances effects of nutritional intervention
on obesity, bright liver, and insulin resistance. Dig Dis Sci 2012, 57:535-44.
56. Catalano D, Martines GF, Spadaro D, Di Corrado D, Crispi V, Di Nuovo S,
et al: Quality of life in diabetes. Clin Ter 2004, 155:175-8.
57. Trovato GM, Catalano D, Martines GF, Spadaro D, Garufi G, Di Corrado D,
et al: Illness perception questionnaire (IPQ-r): an useful paradigm in
chronic disease. Recenti Prog Med 2006, 97:129-33.
58. Trovato GM, Pace P, Salerno S, Trovato FM, Catalano D: Pain assessment in
fibromyalgia and rheumatoid arthritis: influence of physical activity and
illness perception. Clin Ter 2010, 161:335-9.

doi:10.1007/s13167-012-0141-2
Cite this article as: Trovato: Behavior, nutrition and lifestyle in a
comprehensive health and disease paradigm: skills and knowledge for
a predictive, preventive and personalized medicine. EPMA Journal 2012
3:8.

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