What is the data telling us?

How big a problem is it?

• A third of all Texas deaths are due to CVD (2006):– Heart disease: 41,000

– Stroke: 9,900

• Hospitalizations in Texas (2006): >265,000– $11.4 billion

– >$1 million every hour

• Texas adults (2008): have had a heart attack – Men: 4.6% Women: 3.4%

• Texas adults (2008): have had a stroke– Men: 2.2% Women: 2.7%

What can we do about it?

• Prevent risk factors that lead to conditions that lead to heart disease (2008 BRFSS)– Inadequate fruits and vegetables: 74.8% (2007)

– Overweight and obesity: 66.2%

– No physical activity: 28.5%

– Smoking: 18.5%

• Detect & manage conditions leading to heart disease– High cholesterol: 38.5%

– High blood pressure: 27.8%• Poor control, 60+ years: men-36%, women-54%

– Diabetes: 10.3%

– Elevated global CVD risk: aspirin chemoprophylaxis

• Manage heart disease

(NHANES : 1999-2004). (NHANES : 1999-2004). Source: NCHS and NHLBI.Source: NCHS and NHLBI.

52.3

35.8

24.6

62.5

39.8

68.474.6 75.3

34.3

01020304050607080

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Pe

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Extent of awareness, treatment and control of Extent of awareness, treatment and control of high blood pressure by agehigh blood pressure by age

(NHANES: 1999-2004).(NHANES: 1999-2004).Source: NCHS and NHLBI.Source: NCHS and NHLBI.

63.4

37.2

66.9

33.6

49.1

25.1

72.9 76.9

62.4

0

10

20

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40

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60

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NH Whites NH Blacks Mexican Americans

Awareness, Treatment and Control of Awareness, Treatment and Control of High Blood Pressure by Race/EthnicityHigh Blood Pressure by Race/Ethnicity

Diabetes Prevalence in Texas, 2007 BRFSS

Race/ethnic group Age Group Prevalence

White 18 to 44 3.0%

African-American 18 to 44 3.7%

Hispanic 18 to 44 6.8%

Other 18 to 44 3.8%

White 45 to 64 10.9%

African-American 45 to 64 17.6%

Hispanic 45 to 64 20.2%

Other 45 to 64 21.1%

Prevalence of Prediabetes or DM, NHANES US

Age PreDM Pre or DM

20 to 39 17.9% 21.1%

40 to 59 30.6% 47.0%

60 to 74 36.8% 66.7%

Pre-Diabetes• Prevalence (20+ years):

– White: 29.3%– Black: 25.1%– Mexican-American: 31.7%

• Among adults with pre-diabetes, the prevalence of cardiovascular (heart) disease risk factors was high: – 94.9% had dyslipidemia (high blood cholesterol); – 56.5% had hypertension (high blood pressure); – 13.9% had microalbuminuria, a protein found in

blood plasma and urine that can signal kidney disease; and

– 16.6% were current smokers.

Diabetes Care, February 2009

Diabetes Prevention• Diabetes prevention studies for persons with

pre-diabetes and overweight/obesity avoids about half of disease onset

• Structured programs that emphasize lifestyle changes and – regular physical activity (150 min/week),– dietary strategies including reduced calories and

reduced intake of dietary fat– include moderate weight loss (7% body weight)

• Individuals at high risk for type 2 diabetes should be encouraged to eat– dietary fiber (14 g fiber/1,000 kcal) and – foods containing whole grains (one-half of grain

intake)

AHA Clinical Performance Measures for Primary Prevention CVD

• Screen: risk factors

• Counsel: healthy eating

• Counsel: regular PA

• Screen: tobacco use

• Tobacco cessation

• Screen: obesity, abd

• Counsel: healthy weight

• Screen: hypertension

• BP control

• Screen: dyslipidemia • LDL control

• Screen: global CVD risk

• Aspirin prophylaxis

Clinical Preventive Services CPB CE Total

Discuss daily aspirin use—men 40+, women 50+ Childhood immunizations Smoking cessation advice and help to quit—adults

555

555

10

Alcohol screening and brief counseling—adults 4 5 9

Colorectal cancer screening—adults 50+ Hypertension screening and treatment—adults 18+ Influenza immunization—adults 50+ Vision screening—adults 65+

4543

4345

8

Cervical cancer screening—women Cholesterol screening and treatment—men 35+, women 45+ Pneumococcal immunizations—adults 65+

453

324

7

High Value Preventive Services

What can we do about it?• A: Avoid tobacco • B: Be more active: 30 minutes of walking

– Improves blood pressure by 4-9 “points”– 75 calories most days: 5 pounds a year

• C: Choose healthier foods: more fiber, less saturated fat, less salt– Improves blood pressure: 10-15 “points”– Improves bad cholesterol: 20 “points”– 10 pound weight loss improves bad

cholesterol by 10 “points”

What can “we” do about it?

• Make healthier choices the easier choices

• More convenient • Lower cost• More access• More support

What can we do about it?

• A: Avoid tobacco

• B: Be more active

• C: Choose healthier foods

• Behavior change is more likely when benefits are likely and quickly visible, and

• Reasons for change are more important than reasons for not changing, and

• Confidence to make the change

Decreasing sodium intake• 60% of adults have elevated blood pressure

• Average intake: 4000 mg (~75% added) 2300 mg

• Adequate intake: 1500 mg for healthy, 19-50 years

• AMA adopts directives at annual meeting 2006

• FDA has been asked to revoke the "generally recognized as safe" status to a “food additive”

– a stepwise 50% reduction

– improve labeling to assist consumers in understanding the amount of sodium

– social marketing for consumer awareness

• 150,000 fewer deaths a year by decreasing hypertension by 20% in ages 25-55 with a 50% reduction in sodium

AHA 2006: Dietary approaches to prevent and treat HTN

• Available data strongly support population-wide recommendations to lower salt intake.

• Consumers should choose foods low in salt and limit the amount of salt added to food.

• However, because >75% of consumed salt comes from processed foods

– any strategy to reduce salt intake must involve the efforts of food manufacturers and restaurants

– should progressively reduce the salt added to foods by 50% over the next 10 years.

Population-based Strategy Effects of Lowering SBP Distributions

Population-based Strategy Effects of Lowering SBP Distributions

 Stamler J. Hypertension 1991;17:I-16–I-20. Stamler J. Hypertension 1991;17:I-16–I-20.

Reduction in BPmm Hg

2

3

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Reduction in BPmm Hg

2

3

5

% Reduction in Mortality % Reduction in Mortality

Reduction in BP

Reduction in BP

After interventionAfter intervention Before interventionBefore intervention

Stroke CHD Total

-6 -4 -3

-8 -5 -4

-14 -9 -7

Copyright ©2006 American Heart Association

Appel, L. J. et al. Hypertension 2006;47:296-308

Mean systolic BP changes in the DASH-Sodium trial

Relative Risk of Developing CHD vs. Systolic Blood Pressure

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Neaton JD. Arch Int Med 1992; 152:56-64.

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Reduce adult obesity, Texas, 2007

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Per

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US Texas HP 2010 goal

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Year

Per

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US Texas HP 2010 goal

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Reduce Texas youth smoking 2007 YRBS

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Preventive Services, TX, 2007 BRFSS

• Tobacco smokers

– Advised to quit: 40% (Hispanic 27%)

– Offered NRT: 22% (Hispanic 11%)

• Cholesterol screening, men: 78% (Hispanic 63%)

• Received weight advice

– Obese: 34%

– Overweight: 13%

Smoking

• Smoking costs an estimated $92 billion per year in lost productivity in the US.

– Lost productivity due to smoking and smoking related illnesses cost employers $1,897 per smoking employee per year (2002 dollars)

– If 20% of 250,000 employees smoke (50,000) then the annual loss is over $ 100 M per year

– If 20% of 12,000 employees smoke (2,400) then the annual loss is over $4.5 M per year

Physical Inactivity

• Regular physical activity reduces the risk of developing diabetes, high blood pressure and some cancers and promotes psychological wellbeing.

• Productivity costs in 250,000: $579 M per year

• Productivity costs in 12,000: $27.8 M

http://www.ecu.edu/picostcalc/

Review• CVD

– Common– Costly– Can be prevented

• Environmental change and behavior change– Non-pharmacotherapy is key to prevention and

management of conditions leading to CVD

• Opportunities for improvement• Engage community stakeholders