Heart Disease and Stroke in Utah 2010

Heart Disease & Stroke In Utah, 2010

Robert T. Rolfs, MD, MPHDirector, Div. Disease Control and Prevention

State EpidemiologistUtah Department of Health

Key Points

1. Utah and the US have experienced significant declines in mortality from heart disease and stroke. Some factors that contribute to this include population-wide lifestyle changes, such as increased physical activity and decreased cigarette smoking.

2. High blood pressure patients have a higher prevalence of risk factors and co-morbidities compared to the general population. The health care system is not adequately controlling high blood pressure, despite widely available and relatively inexpensive treatment options.

3. Sodium is emerging as an important for controlling high blood pressure.

Burden of Heart Disease & Stroke in Utah

• In 2008, 3,562 Utahns died of cardiovascular disease, the leading cause of death in Utah.

• Average age at death from heart disease and stroke:– Males: 76 years old

– Females: 81 years old

Source: Utah Death Certificate Database, ICD 10 Codes I00-I78. Age-adjusted to the 2000 U.S Standard Population

Utah Heart Disease Deaths, 1999-2009

Mortality Rate

191.75

135.54

0

50

100

150

200

250

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Average Age at HD Death

77.98 77.9

6062646668707274767880

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Decreased by 29% in 11 years

No change

Source: Utah Death Certificate Database, ICD 10 Codes I00-I09, I11, I13, I20-I51. Age-adjusted to the 2000 U.S Standard Population

Utah Coronary Heart Disease Deaths, 1999-2009

Mortality Rate

118.27

66.34

0

20

40

60

80

100

120

140

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Rate

per

100

,000

Pop

.

Average Age at CHD Death

77.37 76.22

60

65

70

75

80

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009


No change

Source: Utah Death Certificate Database, ICD 10 Codes I20-I25, I11. Age-adjusted to the 2000 U.S Standard Population

Utah Stroke Deaths,1999-2009

Mortality Rate

61.32

36.01

0

10

20

30

40

50

60

70

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Rate

per

100

,000

Pop

.


Source: Utah Death Certificate Database, ICD 10 Codes I60-I69. Age-adjusted to the 2000 U.S Standard Population

Utah Stroke Deaths

80.6

78.7

70

72

74

76

78

80

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Avg. Age at Stroke Death Decreased by 2 years over 11-year period.

Utah Hospital Discharges

16.83 13.69

54.22

26.59

0

10

20

30

40

50

60

70

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Rate

per

10,

000

Pop.

1992-2008Stroke CHD

19% Decrease

51% Decrease

Source: Utah Death Certificate Database, ICD 9 Codes 430-434, 436-438 (cerebrovascular disease), 410-414, 429.2 (CHD), 428 (HF) . Age-adjusted to the 2000 U.S Standard Population

Status of Risk Factors in Utah

15.50%

9.10%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Cigarette Smoking Decreased by 41.3% in 19 years

Age-adjusted to 2000 U.S. Population. Source: Utah Behavioral Risk Factor Surveillance System

52.8%56.6%

0%

10%

20%

30%

40%

50%

60%

2001 2003 2005 2007 2009

Recommended Physical Activity Increased by 7.2% in 8 years




39.30%

59.50%

0%

10%

20%

30%

40%

50%

60%

70%

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Overweight or Obesity

Years 1989-2009 Years 1989-2008.

Age-adjusted to 2000 U.S. Population, adults 18+ only. Source: Utah Behavioral Risk Factor Surveillance System

Increased by 51.4% in 20 years


3.70%

7.00%

0%

1%

2%

3%

4%

5%

6%

7%

8%

Diabetes Increased by 89.2% in 19 years



20.76%

25.42%

0%

5%

10%

15%

20%

25%

30%

1995 1997 1999 2001 2003 2005 2007 2009

Dr. Diagnosed High Blood Pressure


Increased by 22.4% in 14 years


16.40%

25.88%

0%

5%

10%

15%

20%

25%

30%

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Dr. Diagnosed High Cholesterol Increased by 57.8% in 18 years


“A NEGLECTED DISEASE”: HIGH BLOOD PRESSURE

The Institute of Medicine Report on Hypertension

High Blood Pressure

• Most common primary care diagnosis in the US

• Affects about 23% of Utah adults

• Contributes to 45% of all cardiovascular deaths in the US

• Accounts for 1 in 6 all US adult deaths

• Estimated direct and indirect costs, 2009: $73.4 billion

Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press.

A “Neglected Disease”

• The health impact and cost of high blood pressure is well-documented.

• The risk factors that contribute to HBP are highly prevalent.

• Evidence-based interventions to control HBP are well established and relatively cheap.

• We are failing to translate our public health and clinical knowledge into effective prevention, treatment, and control.


“Lack of physician adherence to HBP treatment guidelines is a major problem and significant

reason for the lack of awareness, lack of pharmacological treatment, and lack of

hypertension control in the United States.”

Inadequate Primary Care



• HBP control is inadequate even when patients have access to health care and a usual place of care.

• 86% of individuals with uncontrolled HBP have a usual source of care and average 4.3 physician visits per year.

• Few physicians encourage patients to make lifestyle modifications, such as healthy diet and exercise, to control their HBP.


• Physicians are unlikely to treat or to intensify treatment for mild to moderate systolic HBP (<165mmHg) if the DBP <90mmHg

• In one study, of those with a 24-month avg. BP >140/90, 25% not diagnosed with HBP. 2/3 were not diagnosed if BP was 140-59/<90.

• Of those on meds, the avg BP was 147/86, and only 24% had HBP<140/90

• Few physicians encourage patients to make lifestyle modifications that are known to be effective in controlling HBP.


Patient Nonadherence

• 50% of patients discontinue drug treatment after 1 year.

• Noncompliance with HBP meds = increased hospital admissions.

• Continuous HBP medications = statistically significant reductions in hospital expenditures per patient that are greater than the accompanying drug costs.


Patient Nonadherence

• 92% of persons with uncontrolled HBP have insurance.

• Income and high out-of-pocket costs = underuse of HBP medications

• Increased attention from providers in identifying barriers to medication adherence could help to address this.


HIGH BLOOD PRESSURE: THE BURDEN IN UTAH

High Blood Pressure Prevalence

14%

5%

21%

11%

40%34%

55%60%

0%

10%

20%

30%

40%

50%

60%

70%

M F M F M F M F

18-34 35-49 50-64 65+

By Age and Sex, 2009

Source: Utah Behavioral Risk Factor Surveillance Survey

High Blood Pressure Diagnoses

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Age Group

<18 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

Coun

t

2009

Source: Utah All-Payer Database, ICD 9 Codes 401-405


29%31% 30%

24%

0%

5%

10%

15%

20%

25%

30%

35%

Less Than High

School

H.S. Grad or G.E.D.

Some Post High

School

College Graduate

By Education Level, 2009

33%29% 28%

23%

0%

5%

10%

15%

20%

25%

30%

35%

By Income Level, 2009

Source: Utah Behavioral Risk Factor Surveillance Survey. Age-adjusted to 2000 U.S. Standard Population.


22.2% 22.4%

27.7%

23.1%

0%

5%

10%

15%

20%

25%

30%

Hispanic or Latino White, non-Hispanic

Other, non-Hispanic

All Utahns

By Ethnicity, 2005, 2007, 2009



25.3% 24.2%

34.6%

26.7%

22.3% 21.4% 22.3%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Amer. Ind. Asian Black Pac. Isl. White Other Total

By Race, 2003, 2005, 2007, 2009


A Sentinel Indicator for Disparities

• Nationally, high blood pressure is associated with racial and ethnic health disparities.

• These disparities occur along the entire spectrum from risk factors to the delivery of medical care.

• Targeting interventions toward a general population historically do not correct these inequities and can even worsen them.

• Because HBP is so closely linked to other risk factors associated with race and class, it can be useful in measuring the effectiveness of approaches to reduce health disparities.


HBP and Co-Occurring Risk Behaviors

10.8

15.1

13.2

16.1

8.3

13.2

0

2

4

6

8

10

12

14

16

18

Gen HBP Gen HBP Gen HBP

Total M F

Cigarette Smoking

Source: Utah Behavioral Risk Factor Surveillance Survey, 2005, 2007, and 2009 combined years. Age-adjusted rates.

1.4X higher 1.6X

higher


59.2

78.6

67.3

81.9

50.6

74.2

0

10

20

30

40

50

60

70

80

90


Total M F

Overweight or Obese

Source: Utah Behavioral Risk Factor Surveillance Survey, 2005, 2007, and 2009 combined years. Age-adjusted rates.

1.3X higher

1.2X higher 1.5X

higher

55.752.1

56.2 54.8 55.248.4

0

10

20

30

40

50

60

70


Total M F

Meet Physical Activity Recommendations Not significantly different from state.


3.70%

7.00%

0%

1%

2%

3%

4%

5%

6%

7%

8%

19891990199119921993199419951996199719981999200020012002200320042005200620072008

Diabetes Increased 89.1% in 19 years


Taking Medication to Control HBP

54.5%52.2%

44.9%

53.3% 54.3%

0%

10%

20%

30%

40%

50%

60%

2001 2003 2005 2007 2009

% Dr. Diagnosed HBP on meds

Source: Utah Behavioral Risk Factor Surveillance System. Age-adjusted to 2000 U.S. Standard Population.

HBP in Utah: Conclusions

• Although HBP is associated with age, many factors influence its distribution across other demographic groups. Older, lower-income, less-educated, and racial and ethnic minority populations bear a higher burden. Approaches targeting the “general” population are unlikely to resolve disparities.

• The health care system must use comprehensive evidence-based approaches to support lifestyle change and medical management to adequately address the high prevalence of co-occurring risk factors and co-morbid conditions among people with HBP.

• Public health agencies and partners must continue to advocate for policies and processes that improve high blood pressure prevention and control.

HBP in Utah: Conclusions

• HBP continues to be a challenging area for state-level surveillance. We need to push for increased access to clinic-level data, such as blood pressure levels, in order to truly estimate the prevalence and control of high blood pressure.

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”-Goethe

Sodium Reduction: State and Local Action Opportunities to Reform the Norm

38

From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.

39

• Excess sodium intake is a primary risk factor for high blood pressure.

• Most of the sodium in our food supply is invisible in processed and restaurant foods. Consumers have little control over the amount of sodium in their diet.

• It can be difficult for even the most motivated consumer to reduce sodium intake.

Sodium Reduction: A Public Health Imperative

IOM (Institute of Medicine). 2005. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate. Washington, DC: The National Academies Press.

Sodium and High Blood Pressure

• Increased sodium in the diet → increased blood pressure → increased risk for heart attack and stroke. – Generally, lower consumption of salt means lower blood

pressure.

– Within weeks on average, most people experience a reduction in blood pressure when salt intake is reduced.

• Even people with blood pressure in the optimal range benefit from sodium reduction and reduced risk for heart attack and stroke.

• Reducing sodium = reducing mortality.

40


Sodium Reduction: A Public Health Imperative

• Sodium reduction can have a significant impact on reducing disparities and cardiovascular disease events.

• Reducing sodium in the food supply is the best population-based strategy to reduce the prevalence of high blood pressure.

41


Sodium Intake Recommendations

• The 2005 Dietary Guidelines for Americans recommend less than 2,300 mg per day for the general population.– For specific populations—70 percent of U.S. adults—limit intake

to 1,500 mg per day.

• Average daily sodium intake for U.S. adults is more than 3,400 mg per day.

42

IOM (Institute of Medicine). 2005. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate. Washington, DC: The National Academies Press. Centers for Disease Control and Prevention. Application of lower sodium intake recommendations to adults—United States,1999–2006. MMWR. 2009;58(11):281–3. U.S. Department of Agriculture. What we eat in America. Available from http://www.ars.usda.gov/service/docs.htm?docid=15044

Sources of Sodium

During cooking5%

At the table6%

Naturally occurring

12%

Food processing77%

43

Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 Aug;10(4):383-93.

Why Action is Needed at State and Local Levels

• Strong scientific evidence supports the need for population-wide sodium reduction due to the harmful impact of sodium on blood pressure.

• Individual behavior change is difficult.

• The most effective population approach to reducing sodium intake is to reduce the sodium content of restaurant and processed foods, which contribute the vast majority of sodium in the food supply.

• All current approaches are voluntary.

44


45

Estimated Effects on HBP Prevalence and Related Costs from Sodium Reduction

• Reducing average population intake to 2,300 mg per day (current recommended limit) may…– Reduce cases of HBP by 11 million.

– Save $18 billion in health care spending.

– Gain 312,000 quality-adjusted life years (QALYs).

• Even fewer cases of HBP and more dollars saved if intake was reduced to 1,500 mg per day (recommended maximum level for “specific populations”).

Palar K, Sturm R. Potential societal savings from reduced sodium consumption in the U.S. adult population. Am J Health Promot. 2009 Sep-Oct;24(1):49-57.

Global Sodium Reduction

• Not just a public health issue for the United States.– HBP is the primary contributor globally to heart disease and

stroke.

• Reformulation of products has occurred in other countries.– Sodium content of identical products in other countries can be

significantly lower.

• Some countries, such as the United Kingdom, Australia, and Canada, are leading the way in sodium-reduction efforts.

• Sodium reduction and tobacco control = recommendations to improve health in developing countries .

46From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.

International: Product Variability

Sodium per serving

Sodium per 100 gm

Brazil 1,300 mg 349 mg

Australia 1,153 mg 321 mg

US 1,090 mg 291 mg

Germany 1,010 mg 285 mg

Canada 980 mg 263 mg

UK 875 mg 246 mg

Italy 819 mg 231 mg

Sodium per serving

Sodium per 100 gm

Canada 270 mg 931 mg

Mexico 260 mg 867 mg

US 220 mg 710 mg

France 200 mg 450 mg

Italy 200 mg 450 mg

UK 100 mg 450 mg

Turkey 200 mg 400 mg

47

Burger King Double Whopper

World Action on Salt and Health.

Kellogg’s Special K

What Has Been Done to Reform the Norm Abroad?

Several countries have taken action on sodium reduction.

• Finland: The country’s initiatives have resulted in a significant decrease in average population salt intake.

• United Kingdom: Average sodium intake in the population has already been reduced by 360 mg.

• Australia: Salt database that includes more than 7,000 items identified large variations in the salt content of similar products offered by different companies.

• Canada: Sodium Working Group formed in 2007 to work on a national strategy to reduce sodium consumption.


National Salt Reduction Initiative

• New York City Department of Health and Mental Hygiene has launched a nationwide effort to reduce the level of salt in processed and restaurant foods.

• The partnership includes more than 40 cities, states, and public health organizations.

• The department is working with food industry representatives on a voluntary framework to reduce the salt in their products.

• Initial sodium reduction benchmarks have been set for 61 categories of packaged foods and 25 categories of restaurant foods.


What Has Been Done to Reform the Norm in the United States?

• State and local activity:– Communities Putting Prevention to Work.– Los Angeles County.

• Baltimore City: Salt Reduction Task Force.

• Massachusetts and New York City: Procurement policies.

• Seattle/King County and others: Menu labeling.

50


Sodium Landscape

• IOM’s “Strategies to Reduce Sodium in the United States”.

– Lay the groundwork for action.

• Food and Drug Administration to review IOM recommendations and work with other agencies and organizations.

• Enhanced surveillance of sodium in foods and foods consumed.

• Fiscal Year 2009 congressional language.


Potential State and Local Strategies

• Procurement policies (federal, state, local, organizational).

• Support voluntary reduction efforts that include benchmarks and accountability (such as NYC).

• Labeling requirements.

• Venue-based approaches.

• Consumer awareness campaigns.

• Letter-writing campaigns.


Healthier Food Environment = Healthier Population

• Changing the food environment gives consumers a broader range of healthful foods from which to choose.

• Policy and environment strategies are effective at the state and local level and help drive demand for federal action.

• One of the most promising strategies to decrease the prevalence of heart disease and stroke is to lower sodium content of processed and restaurant foods.

• Sodium reduction will benefit most Americans.

53


Additional Resources

• CDC’s Division for Heart Disease and Stroke Prevention Salt Web pagehttp://www.cdc.gov/salt

• Institute of Medicine, Strategies to Reduce Sodium in the United Stateshttp://www.iom.edu/sodiumstrategies

54


http://www.cdc.gov/salt/�

http://www.iom.edu/sodiumstrategies�

Additional Resources

• NYC’s National Salt Reduction Initiative http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml

• Baltimore City’s Salt Reduction Task Force Recommendationshttp://www.baltimorehealth.org/info/2009_09_30_SaltTaskForceReport.pdf

• Seattle/King County’s Nutrition Labeling http://www.kingcounty.gov/healthservices/health/nutrition/healthyeating/menu.aspx

55


http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml�

http://www.baltimorehealth.org/info/2009_09_30_SaltTaskForceReport.pdf�

http://www.kingcounty.gov/healthservices/health/nutrition/healthyeating/menu.aspx�

http://www.kingcounty.gov/healthservices/health/nutrition/healthyeating/menu.aspx�

Documents

Heart Disease and Stroke in Utah 2010