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CDC Encourages Community Actions To Help Individuals Adopt Heart-Healthy LifestylesMarch 21, 2005 The U.S. Centers for Disease Control and Prevention (CDC) and state-level heart disease and stroke prevention programs are encouraging communities to create environments where it is easier for individuals to make heart-healthy choices. That means changing both the physical and social environment to be more supportive of positive health choices that individuals can make every day. Preventing heart disease is a lifelong endeavor, and health policy experts now recognize that depending on individual health behaviors alone may not lead to improved health and quality of life. CDC urges communities and states to take action to ensure there are more smoke-free areas, better parks and walking courses, free blood pressure screenings, more vending machines and cafeterias offering heart-healthy options, health insurance plans that focus on preventive care, and education programs targeting all ages, starting with children in school. There is also an increased emphasis on educating the public to recognize and respond to heart attacks, and on shoring up the emergency response system through expanded and better-trained 9-1-1 emergency services. The goal is not just to prevent people dying from heart attacks in old age. Rather, concern should focus on avoiding the lingering disability that can alter the quality of life for middle-aged and older adults forever, according to Nancy Watkins, M.P.H., the Team Leader for Program Services within CDC’s Cardiovascular Health Branch. “Too many people think that dying from heart disease means passing away in their sleep when they are 90 years old, but that is not the reality,” Watkins said. “We are trying to put a face on premature heart disease and stroke, and on the amount of disability and loss of quality of life that comes with these diseases.” Heart disease is largely preventable. Most people know they should manage their blood pressure and cholesterol, avoid tobacco, stay physically active, and eat a healthy diet low in fat and salt to maintain good heart health. Yet, despite decades of public education, heart disease continues to be the number one cause of all deaths for both women and men in this country. It is also a leading cause of premature, permanent disability in the workplace. Heart disease alone accounts for 19 percent of Social Security Administration disability allowances, the American Heart Association reports. “CDC-funded heart disease and stroke prevention programs in state health departments are focusing efforts within states to prevent heart disease and stroke,” said Dr. Darwin Labarthe, Acting Chief of the Cardiovascular Health Branch. “State programs are working to increase awareness and to put in place policy and environmental supports that make it easier for individuals to make heart-healthy choices. Important policy and environmental supports are being implemented through on-going collaborations with partners from healthcare, schools, worksites, insurance providers and community stakeholders.” THE STATISTICS OF HEART DISEASE Cardiovascular disease (CVD), which includes heart disease and stroke, affects 70 million Americans, causes more than 6 million hospitalizations annually and kills nearly 930,000 people each year, accounting for nearly 40 percent of all deaths in this country, according to CDC. That means about one out of four people in the United States has some form of CVD. Although death rates for CVD decreased in the 1980s and 1990s, the actual number of deaths increased because of population growth. “It is still a huge economic burden on states, Medicaid, Medicare and the nation,” Watkins said. The aging of the 76 million baby boomers in this country is expected to sharply increase the number of people with cardiovascular disease. Roughly 1 million people in the United States have a heart attack each year. About every 26 seconds, someone in this country has some type of coronary disease event. Among those who have had heart attacks, 66 percent do not fully recover, and 25 percent of men and 38 percent of women who have a heart attack die within a year, according to data from the National Heart, Lung and Blood Institute’s (NHLBI) Framingham Heart Study. Heart disease is a serious and costly illness. In 2005, heart disease in the United States is projected to cost $254.8 billion, including healthcare services, medications and lost productivity, according to the American Heart Association [Heart Disease and Stroke Statistics—2005 Update]. High blood pressure (hypertension) is a major risk factor for both heart disease and stroke, Watkins said. Hypertension occurs in more than two-thirds of individuals after age 65, the NHLBI reports. It affects approximately 65 million individuals in the United States. Other major risk factors for heart disease and stroke include high blood cholesterol, smoking, having diabetes, poor nutrition, and physical inactivity. DISPARITIES IN DISEASE BURDEN Much of the health disparities between racial and ethnic groups can be attributed to heart disease [Morbidity and Mortality Weekly Report, Sept. 14, 2001]. Thus, reducing heart and other CVD can have the greatest impact on reducing disparities, Watkins said. CDC attributes one-third of the life expectancy gap between blacks and whites to heart disease. Age-adjusted death rates were 30 percent higher for African Americans than whites in 2002. The age-adjusted rate of heart disease deaths per 100,000 population in 2002 was 371 for African American men, 294 for white men, 263 for African American women, and 192 for white women [Health, United States, 2004]. These disparities are partly attributable to the higher prevalence of lifestyle risk factors, high blood pressure, obesity, and diabetes among non-white racial and ethnic groups, CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) states. The latest 1999-2002 data from the NCCDPHP show that only 29 percent of U.S. adults with hypertension had their blood pressure under control [Racial/Ethnic Disparities in Prevalence, Treatment, and Control of Hypertension]. The proportion with controlled blood pressure was substantially lower among Mexican Americans (17.3%). Researchers are studying reasons for heart disease disparities among population groups. For example, African Americans may be at higher risk for death from cardiovascular disease because they have a greater risk for strokes and a higher incidence of blood pressure elevation. In addition to lifestyle factors, social factors such as access to care and socioeconomic differences may play a role in disparities. Heart disease also causes more deaths among women than men, partly due to the fact that women represent a larger portion of the older population. Research by Angela Cheung, M.D., Ph.D., at the University of Toronto’s Department of Medicine indicates that bias in pharmaceutical advertisements for cardiovascular disease may affect treatment. Her research team reported that 80 percent of ads published over a two-year period depicted male patients. There were also few non-whites shown in the ads. This may contribute to physicians’ views on patient treatments. The author noted that the vast majority of scientific evidence is based on research on males [Journal of Evaluation in Clinical Practice, November 2004]. Symptoms of heart disease are sometimes different for women than for men, potentially leading to misdiagnosis or failure to treat promptly and effectively. The research literature indicates that physicians tend to underestimate the prevalence of heart disease among women. PREVENTION IS THE BEST APPROACH Public health efforts focus on preventive approaches such as controlling high blood pressure and cholesterol; educating the public about the signs and symptoms of heart attack and calling 9-1-1; improving emergency response to get a patient to care; improving the quality of care once a patient gets to the hospital; and eliminating heart disease disparities among minorities. “Prevention can be initiated at any stage,” said Cardiovascular Health Branch senior epidemiologist Kurt Greenlund, Ph.D. For those who do not have heart disease, research indicates that lowering high blood cholesterol and high blood pressure can reduce their risk. For someone who already has CVD, the goal is to prolong life and/or improve quality of life. “The best bet is prevention in the first place, of course, but there are always things that people can do to improve their situation even if something has already happened,” Dr. Greenlund said. Research shows that a 12-13 point reduction in systolic blood pressure can reduce heart attacks by 21 percent, strokes by 37 percent and total cardiovascular deaths by 25 percent, Watkins said, citing data from Dr. Jiang He et al. of Tulane University [American Heart Journal, September 1999]. Research indicates that physicians may not be as aggressive as they should be in addressing hypertension in its mild stages. “Most cases of uncontrolled hypertension in the United States consist of isolated, mild systolic hypertension in older adults, most of whom have access to healthcare and relatively frequent contact with physicians,” concluded David J. Hyman et al. of the Baylor College of Medicine, based on data from the National Health and Nutrition Examination Survey of 16,000 adults. The Baylor team found that only 23 percent of those with high blood pressure were taking medication for the condition [New England Journal of Medicine, Aug. 16, 2001]. Once people reach middle age, there is “a good chance they will develop hypertension within their lifetimes,” Watkins said. Individuals with normal blood pressure at age 55 have about a 90 percent lifetime risk for developing hypertension. “There have been a growing number of studies coming out that have looked at risk factor status in middle age, and then outcomes later on, including mortality, quality of life, and Medicare costs,” Dr. Greenlund said. Researchers at Northwestern University have been studying one group of patients since the 1960s. That group is now Medicare age. The research found that people with lower, more beneficial risk factor profiles at about age 50 “have much better outcomes once they reach Medicare age. The data are really coming out now showing the importance of prevention even in middle age,” Dr. Greenlund said. Lifestyle choices are important to prevent and control high blood pressure, including weight reduction, physical activity, a diet rich in potassium and calcium and low in sodium, and moderate alcohol consumption. The DASH diet (Dietary Approaches to Stop Hypertension) — which includes lots of fruits, vegetables, and low-fat dairy products and a limit of 1,600 mg of sodium a day — produces results similar to drug therapy to lower blood pressure in many people. The relatively new diagnostic category of “prehypertension” (systolic blood pressure of 120 to 139 mmHg or a diastolic blood pressure of 80 to 89 mmHg) reinforces the prevention message. People in this category require health-promoting lifestyle modifications to prevent CVD. Those in the 130 to 139 mmHg systolic and 85 to 89 mmHg diastolic ranges have twice the risk of developing hypertension as those with normal blood pressure (less than 120/80). Because patients with prehypertension are at increased risk of progressing to hypertension, “a diagnosis of prehypertension is a good way to emphasize that if you don’t do something about it, you are likely going to be moving into the hypertension category,” Dr. Greenlund said. There also is some evidence that physicians refer fewer of their older patients for outpatient cardiac rehabilitation and counseling to prevent a second heart attack. A study by CDC and Kaiser Permanente researchers found that managed care patients 65 years of age or older “were significantly less likely than younger patients to be referred to cardiac rehabilitation” [Journal of Cardiopulmonary Rehabilitation, May/June 2004]. CDC is linking with the CDC funded Prevention Research Center at the University of North Carolina to determine how physicians affiliated with managed care organizations can use prevention indicators to improve the quality of care for their heart and stroke patients. Starting in January 2005, Medicare began covering medical screenings for heart disease and diabetes, as mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173). The U.S. Centers for Medicare and Medicaid Services is working closely with CDC to spread the word about preventive health, including reducing cholesterol levels. WHAT CAN BE DONE AT THE COMMUNITY LEVEL? Activities at the state and community levels — including policy, social, and physical environment changes — can help encourage and maintain individual behavior changes. In Promising Practices in Chronic Disease Prevention and Control: A Public Health Framework for Action, CDC offers examples of model programs for heart disease and stroke prevention. The American Heart Association publication, Guide for Improving Cardiovascular Health at the Community Level lists goals, strategies and recommendations for community action. Efforts at the state level might include creating smoke- free environments, requiring health plans to cover cardiovascular preventive services such as blood pressure and cholesterol screening, subsidizing blood pressure prescriptions for people with limited incomes, shoring up the 9-1-1 system, and setting training requirements for emergency medical providers. Communities can offer blood pressure screening at all fire stations, create more safe areas for physical activity, and ensure 9-1-1 coverage for all localities. In the healthcare arena, preventive services and guidelines should focus on heart disease and stroke and on improving quality of life. Patient management systems can adopt reminders for physicians and call-back postcards for patients. “Having simple systems in place has resulted in a significant increase in the number of people with high blood pressure who have it under control and maintain that control,” Watkins said. In the workplace, employers can offer blood pressure monitoring, ensure a staff member is trained in cardiopulmonary resuscitation (CPR) and defibrillator use, provide time and access to physical activities, establish clean indoor air policies including a smoke-free environment, and offer heart-healthy foods in cafeterias and vending machines. For their part, schools can educate students, faculty and parents about healthy lifestyle choices and provide heart- healthy food selections. KNOW YOUR SYMPTOMS An alarming fact is that 47 percent of those who die of a heart attack in the United States each year do not make it to a hospital. These “pre-transport deaths” are partly attributable to a victim’s denial that they are having a heart attack. “People don’t understand that the symptoms they are having are related to a heart attack or stroke, and they don’t realize that getting medical care quickly can prevent death or greatly lessen disability,” Watkins said. Because so many heart attack deaths occur before the patient reaches the hospital, CDC promotes awareness of the signs and symptoms and the “chain of events” needed to get people to the hospital, Dr. Greenlund said. Only half of the population even knows the signs and symptoms of a heart attack, Watkins added. Despite the chest-crushing trauma frequently displayed on television, many heart attacks start slowly and produce only mild pain or discomfort. Even patients who have had a prior heart attack may not recognize a second one, which could have very different symptoms. Half of men and 64 percent of women who die suddenly from heart disease had no prior symptoms. NHLBI outlines the following common symptoms of heart attack: 1) chest discomfort (uncomfortable pressure, squeezing, fullness, or pain) that may come and go; 2) discomfort in other areas of the upper body (arms, back, neck, jaw, or stomach); 3) shortness of breath; and 4) other symptoms such as breaking out in a cold sweat, nausea or light-headedness. CDC EFFORTS TO PROMOTE HEART HEALTH Other CDC efforts are highlighted below: • Heart Disease and Stroke Prevention Program. CDC funds health departments in 32 states and the District of Columbia to develop programs to promote heart-healthy and stroke-free communities; prevent and control heart disease, stroke, and risk factors; and eliminate disparities among populations. Many of these activities focus on older adults. (See “Model Programs” below.) • Action Plan. Along with a coalition of other federal, state and local agencies, public health partners, associations, and the World Health Organization, CDC developed national goals for preventing heart disease and stroke through 2020 and beyond. A Public Health Action Plan to Prevent Heart Disease and Stroke focuses on prevention, early detection, treatment of risk factors, and prevention of recurrent cardiovascular events. Recommendations include developing new science-based policies for all age groups and healthcare settings; expanding public health training opportunities, model standards and resources; improving data; and encouraging policy-oriented research. • Heart Disease Atlases. To help track the distribution of racial, ethnic and geographic disparities in heart disease and stroke, CDC has developed three “atlases” — national and state maps depicting county-level heart disease death rates among the five largest U.S. racial and ethnic groups. "These atlases really help to define the geographic and racial/ ethnic disparities in heart disease and stroke mortality. They are particularly useful for state health departments and people involved in health planning to focus program efforts and limited resources to areas of greatest need," Dr. Greenlund said. Interactive versions of the atlases showing county or state data are available. • Healthy People 2010. Chapter 12 of Healthy People 2010 — the government goals for addressing the nation’s health — focuses on heart disease and stroke. It calls for reducing coronary heart disease deaths by 20 percent, and increasing the proportion of adults with hypertension whose blood pressure is under control from 18 percent in 2000 to 50 percent by 2010. • Model Programs. In Arkansas, the Heart Disease and Stroke Prevention Program, with CDC funding, formed a Healthy Aging Coalition to help plan for the growth in the aging population with chronic conditions. In Illinois, CDC funded the Coalition of Limited English Speaking Elderly, representing immigrant groups and seniors, to translate two cardiovascular health fact sheets into Chinese, Hindi, Korean, Russian, and Urdu. The Texas Department of Health Services, Texas Department of Aging and other agencies are working to develop policies and systems within the community that facilitate health self-management among older individuals. The Kentucky Department for Public Health, Heart Disease and Stroke Program gave Medicare providers a physician’s toolkit and patient education tools on blood pressure, risk factors of heart disease and stroke, and warning signs of heart attack and stroke. More information on CDC’s heart disease prevention effort is at www.cdc.gov/cvh. FUTURE DIRECTIONS Reducing the risk for the nation’s number one killer is a clear priority. From the scientific evidence, we know what causes heart disease and how to prevent it. The key is to pass that message on to individuals at risk, and convince them to make behavioral changes now to prevent end-of-life disability. Policy and environmental approaches in communities, worksites, healthcare settings, and schools can help people achieve these changes. This media background paper was written by Nancy Aldrich. William F. Benson was senior editor and project manager.
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