Evidence-Based Policy & Systems Interventions for the Prevention of Heart Disease and Stroke

Evidence-Based Policy & Systems Interventions for the Prevention of Heart Disease and Stroke Strategic Alliance for Health- Action Institute Houston, TX April 28, 2010 Chastity L. Walker, DrPH, MPH Office of the Director Division for Heart Disease and Stroke PreventionCenters for Disease Control and Prevention

Disability & Risk of Recurrent CVD Acute CVD Events Low CVD Risk Increased CVD Risk DHDSP Priorities High Blood Pressure Control/Sodium Reduction ABCS Initiative

Cardiovascular DiseaseLeading Cause of Death in the U.S. 80 million people in U.S. (1 in 3 adults) have CVD CVD kills ~865,000 Americans each year (35% of all deaths) – about 2,400 every day 150,000 CVD-related deaths/yr among people under 65 High blood pressure causes >1/3 of strokes >1/2 of chronic kidney disease >1/4 of total heart disease events in women >1/3 of total heart disease events in men

Proportion of Global Deaths Attributable to Leading Risk Factors (2000) High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Lower mortality, developing region Developed region Alcohol Indoor smoke from solid fuels Iron deficiency 0 1 2 3 4 5 6 7 8 Attributable Mortality (In millions; total 55,861,000) Relatively even distribution among country income groups Ezzati et al. WHO 2000 Report. Lancet 2002;360:1347-1360.

Both Clinical and Public Health Progress Contributed to Decreased Heart Disease Deaths, U.S., 1980-2000 Risk factor reductions = ~50% Clinical interventions = ~50% BMI increases Diabetes increases HTN, Statins Physical inactivity Smoking reduction Cholesterol reduction Systolic BP reduction Initial treatments for heart attack or acute angina Secondary preventive therapies Treatments for heart failure Revascularization for chronic angina Ford ES, et al. NEJM 2007:356;23.

Factors that Affect Health Smallest Impact Largest Impact Examples Eat healthy, be physically active Counseling & Education Rx for high blood pressure, high cholesterol, diabetes Clinical Interventions Immunizations, brief intervention, cessation treatment, colonoscopy Long-lasting Protective Interventions Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax Changing the Context to make individuals’ default decisions healthy Poverty, education, housing, inequality Socioeconomic Factors Frieden, TR. A Framework for Public Health Action: The Health Impact Pyramid. Am J of Public Health., 2010

ABCS Framework

Heart Disease and Stroke Are Preventable • Community prevention • Tobacco control • Eliminate artificial trans fat • Reduce dietary sodium • Reduce obesity • Increase physical activity • Clinical prevention • Aspirin use • Blood pressure control • Cholesterol control • Clinical tobacco cessation

Replacing Trans Fat Is Feasible Partially hydrogenated vegetable oil Vegetable shortening and margarine Cakes, crackers, pastries, cookies, pies and hamburger buns Fry oils for French fries, chicken nuggets, fish fillets, and doughnuts • Regular vegetable oils (canola, soy, corn) that have not been hydrogenated, or newly developed trans fat-free fry oils with similar “fry life” • Reformulated shortening and margarine with little or no trans fat • Many food brands are now free of trans fat • Regular oils or newly developed trans fat-free fry oils with longer “fry life”

State & Local Trans Fat Regulations ----------------------------------------- As of 4/16/09 ------------------------------------ Cambridge, MA King Co. WA Needham, MA Boston Wilmington, MA Monroe Co. NY Lynn, MA Newton, MA Albany Co. NY Niagara Falls, NY Minneapolis & St. Paul Brookline, MA Multnomah Co. OR Buffalo, Erie Co. Madison, WI Stamford, CT Oakland Co. MI Suffolk Co. NY Broome Co. NY Nassau Co. NY Westchester Co. NY Philadelphia San Francisco Cleveland Chicago New York City Montgomery Co. MD Chatham Borough, NY Baltimore Louisville, KY Los Angeles Washington, DC Nashville El Paso, TX Proposals enacted Proposals passed but not yet enacted Proposals introduced Proposals considered but not formally introduced (may include formal surveys/studies of trans fat) Proposals include notification/disclosure (not necessarily a ban) Voluntary reduction – educational campaign Boca Raton, FL Miami-Dade Co.

Average consumption of sodium in the United States is far greater than recommended limits 2005 Dietary Guideline recommendation: <2,300 mg/day (1,500 mg for specific populations) Average intake: 3,466 mg/day The majority of sodium consumed comes from processed and restaurant foods. Policy and environmental changes are needed to speed decreases in sodium intake. Why Sodium Reduction?

Salt and High Blood Pressure • High blood pressure (HBP) is a major public health issue and the leading risk factor for heart disease and stroke. • Nearly one in three U.S. adults has HBP • Excess sodium intake is a known risk factor for HBP and, subsequently, cardiovascular events. • HBP’s enormous burden takes an economic toll.* • Sodium reduction can have a significant impact on reducing disparities, cardiovascular events, and economic burden. * Woteki CE. 1992. Eat for Life: The Food and Nutrition Board’s Guide to Reducing Your Risk of Chronic Disease. http://www.nap.edu/openbook.php?record_id=1365&page=118; American Heart Association. Heart Disease and Stroke Statistics – 2010 Update. http://circ.ahajournals.org/cgi/content/full/121/7/e46.

GOAL:National health organizations call for a 50% reduction in the amount of salt in processed and restaurant foods in 10 years Reduce salt content of processed and restaurant foods by 50% Decrease in blood pressure ~40% reduction in population salt intake Lives saved To ensure progress toward the 40% reduction in population salt intake, commit to an interim goal of a 20% reduction in 5 years

IOM Sodium Recommendations “Food retailers, governments, businesses , institutions , and other large-scale organizations that purchase or distribute food should establish sodium specifications for the foods they purchase and the food operations they oversee.”

IOM Sodium Recommendations “Government agencies, public health and consumer organizations, health professionals, the food industry, and public-private partnerships should continue or expand efforts to support consumers in making behavior changes to reduce sodium intake in a manner consistent with the Dietary Guidelines for Americans.”

What Can Communities do to Reduce Sodium ? • Promote voluntary collaborations • Procurement • Support consumers behavior change • Implement innovative initiatives to facilitate and sustain decreased sodium in foods • Implement activities to support and promote policy initiatives to reduce sodium intake • Support and participate in state or local level monitoring and evaluation efforts

Policy Package to Prevent and Reverse Obesity • Price • Decrease cost of fruits and vegetables • Increase cost of unhealthy foods • Exposure • Increase exposure to healthy foods, water • Reduce sugar-sweetened beverage consumption • Junk food to be removed from all schools, health care facilities, government institutions (at minimum) • Image • Restrict ads to kids • Show human impact of nutritionally harmful beverages and foods

Environments and Policies that Promote Physical Activity Urban design and land use to encourage physical activity as part of transportation Minimize long, non-walkable distances Use grid street layouts, build high-density mixed development near public transit Street design that makes walking and biking safe and pleasant Sidewalks, bike lanes, improved lighting, trees Building and site design that does not favor automobiles over pedestrians

ABCS of Heart Disease & Stroke Prevention ASPIRIN BLOOD PRESSURE Sodium Consumption CHOLESTEROL SMOKING

On ABCS, USA Gets an “F” People at increased risk of CVD who are taking Aspirin – 33% People with hypertension who have adequately controlled Blood pressure – 44% People with high Cholesterol who have adequately controlled hyperlipidemia – 29% Smokers who try to quit who get help – 20% Despite spending nearly 1 out of every 6 dollars on health care

Aspirin Use IncreasingBut Under-Prescribed for U.S. Patients at Risk of CVD High risk Multiple risk factors % of patients using aspirin % of patients using aspirin DM Low risk Stafford RS, et al. PLoS Med 2005;2:e353.

Why Hypertension (Blood Pressure)? • Affects nearly 1 in 3 US adults • Leading risk factor for heart disease and stroke • 65% of people with hypertension do not have it under control • Prevalence has increased from Healthy People 2010 baseline • $73.4 billion (2009) in estimated direct and indirect costs • A population shift in SBP of 12-13 points could reduce: • heart attacks by 21% • strokes by 37% • total CVD deaths 25%

IOM Hypertension (HBP) Recommendations • Population-based Approaches • Improve Surveillance and Reporting of HTN and Risk Factors • Leadership in Reducing Sodium Intake and Increasing Potassium Intake • Improve Quality of Care to Individuals with HTN • Remove Economic Barriers to Effective Antihypertensive Meds • Provide Community Support for Individuals with HTN • Support Measurement and Accountability

Hypertension Prevention and Control • Expand Access to Care and Treatment • Decrease out of pocket costs of HTN and cholesterol medications (e.g., bulk purchase) • Integrate HTN with other chronic disease efforts (e.g., nutrition, diabetes, physical activity, obesity) • Implement/expand use of auxiliary health workers • Promote High Quality Services • Increase reimbursement of clinical and community-based services • Enhance Clinical/ Community-based Social Supports • Improve adherence to guidelines • Quitline or other counseling/cessation * Green BB et al. JAMA 2008;299:2857-67

Cholesterol • Having high blood cholesterol puts one at risk for heart disease. • 1 in 6 six adults- 16.3% of U.S. adult population- has high cholesterol (240 mg/dL and above); approximately twice the risk for heart disease. • High LDL-Cholesterol (160 mg/dL and above )= “Bad" cholesterol • LDL-lowering therapy reduces total mortality, coronary mortality, major coronary events, coronary artery procedures, and stroke in persons with established CHD.

Smoking • Smoking causes CVD. • Cigarette smokers are 2–4 times more likely to develop coronary heart disease than nonsmokers. • Cigarette smoking approximately doubles a person's risk for stroke. • Nonsmokers exposed to secondhand smoke at home or work increase heart disease risk by 25–30% and lung cancer risk by 20–30%.

Clinical Smoking Cessation Guidelines • Tobacco dependence is a chronic condition that often requires repeated intervention. • Evaluate tobacco use of every patient at every visit. • Every patient who uses tobacco should be offered tobacco cessation services • 3-5 minutes of counseling can increase quit rates • Medications are effective and should be offered to every patient attempting to quit • Only 6 states cover all proven treatment through Medicaid at present. Fiore MC et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. 2008.

Quitline Counseling Alone or with Medication Increases 6-Month Abstinence Rates Percent Quit Source: Clinical Practice Guideline Meta-Analysis Results. Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May.

Community-Level Interventions Reduce Costs • Change Environment • Healthy Choice is Default Choice • Scalable • Evidence-Based • Measureable • Support Peer-to-Peer Learning

WISEWOMAN: Flow of Services Women Recruited from NBCCEDP Program Heart Disease and Stroke Risk Factor Screening Risk Reduction Counseling and Referral Abnormal Assessment of Lifestyle Behaviors and Readiness to Change Medical Referraland diagnosis Lifestyle Intervention(s) Risk Factors Prevented or Reduced

The Asheville (NC) Project • Employer sponsored Chronic Disease • Self- Management Program • Trained Health Educators and Pharmacists • Reimbursement/ Co-pay reduction • Increase in blood pressure and cholesterol control • Decrease in CVD event rates • Decrease in CVD related costs • Decrease in costs of CVD events, to $9,931 from $14,343 or $4412 per event

Critical SHAPP Components • Easy enrollment • Dedicated staff • Affordable medication • Evidence-based treatment protocols • Patient follow-up and monitoring. • Nurse-driven treatment program. Annual cost: $486 Usual care: $624 No care: $534

Mississippi Delta Health Collaborative • ABCS Initiative • Evidence-based policy and systems change strategies (clinical/community) • Implement models for rural chronic disease prevention and health promotion • Develop and implement an integrated chronic disease collaborative model • Robust surveillance, including direct biological measurement • Leveraging other federal and non-federal resources.

Community Health Workers (CHW’s) CHWs add value to health care systems and improve care because they support: • Self-management strategies • Compliance with treatment • Lifestyle changes • Patient education • Access to health care, medications, and other services • Navigation of the healthcare system • Cultural competence of service delivery • Patient and community advocacy

What Actions Have Other States Taken? (CHW)

African American Men & High Blood Pressure Control (Barbershop Initiative)

Tools & Resources www.cdc.gov/dhdsp

CHW Guide Provides • Evidence on effectiveness of CHWs as a strategy to improve the prevention and management of chronic conditions (especially HTN) • Information on existing resources to support the work and development of CHWs • Guidance and examples to public health practitioners about policy and systems strategies

A Closer Look at African American Men and High Blood Pressure Control

Moving Into Action Guides • Update to 2005 Guides built to accompany Action Plan • Purpose: Suggest policy actions across goal areas at federal, state, and local levels • Targeted Guides: • State legislators • Governors • Employers • Local (leaders)

Atlases of Heart Disease and Stroke

Evidence-Based Policy & Systems Interventions for the Prevention of Heart Disease and Stroke