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Improving the Cardiovascular Health of the US Population

Improving the Cardiovascular Health of the US Population Building on the successful accomplishment of its goals for the last decade, in 2010 the American Heart Association (AHA) announced its new Strategic Impact Goals: “By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.”1 The novel aspect of the 2020 goals is the promotion of “cardiovascular health,” a new, positive approach to prevention of cardiovascular disease (CVD). Seven health behaviors and health factors currently define cardiovascular health: smoking status, body mass index, dietary content, participation in physical activity, and levels of blood pressure, blood glucose, and total cholesterol. To encompass the entire spectrum of cardiovascular health (from optimal to uncontrolled levels), each metric has 3 clinically based strata defined as ideal, intermediate, and poor.1 Two key concepts are central to the development and achievement of the AHA's goals. The first concept was promulgated by Rose,2 who noted that prevention efforts can focus on unhealthy individuals or unhealthy populations. With diseases such as CVD, the majority of events occur in the large proportion of the population with average or only mildly elevated levels of risk factors, rather than in the small subset with marked elevations. Therefore, in addition to “high-risk strategies,” “population strategies” must be used to shift the entire population distribution of risk factors toward more favorable levels. When population strategies are successful, small changes in population mean levels can result in large reductions in disease rates.3 The second concept, introduced by Strasser,4 defines population strategies that prevent risk factor development in the first place: so-called primordial prevention. Once a risk factor has developed, it is difficult to reduce risk back to low levels. Pharmacological and lifestyle interventions for secondary and primary prevention, while effective, will not reduce CVD event rates to levels seen in those who maintain optimal risk factor profiles (ideal cardiovascular health) into middle and older ages. In a report in this issue of JAMA, Yang and colleagues5 examine secular trends in cardiovascular health metrics in the US population over the last 20 years. As seen in other analyses,1,6-9 the prevalence of having all 7 factors at ideal levels was less than 2% and remained similarly low over time. Whereas there were some positive trends in smoking, physical activity, blood pressure, and cholesterol levels, there were alarming trends in the decreasing proportion of adults following 2 or more of the 5 dietary components and increases in the prevalence of obesity and impaired fasting glucose levels.5 Given these trends, it is clear that reaching the AHA 2020 goals will be difficult. However, the data also indicate the critical importance of attempting to shift the population toward greater cardiovascular health. Yang et al report associations between the numbers of ideal cardiovascular health metrics and mortality over 14.5 years. Compared with individuals with 0 or 1 metrics at ideal levels, those with 6 or more metrics at ideal levels had 51%, 76%, and 70% lower adjusted hazards for all-cause, CVD, and ischemic heart disease mortality, respectively. Risk reductions were similar for older ages, both sexes, and all race/ethnicity and educational attainment groups, and having 6 or more ideal metrics was particularly associated with avoidance of premature CVD death. Higher numbers of ideal metrics were even associated with lower hazards for cancer mortality.5 These findings are consistent with recent analyses demonstrating similar marked reductions in short-term mortality7 and 20-year fatal and nonfatal CVD event rates8 with higher numbers of ideal cardiovascular health metrics. Thus, the case for the ideal cardiovascular health construct with regard to important outcome events appears to be settled. Further work is needed to examine outcomes in health-related quality of life and health care expenditures. Why do so few Americans have ideal cardiovascular health? The answer is clear. Data from all of the recent studies indicate that the face of ideal cardiovascular health is a young, educated white woman. The pattern of ideal cardiovascular health is the norm in most infants, but it is lost, sometimes rapidly, during childhood, adolescence, and young adulthood through adoption of adverse health behaviors related to diet, weight, and sedentary lifestyle, particularly in populations with lower socioeconomic status. Thus, the nature of the problem transcends the health care and public health systems, and solutions must also come through improvements in the built environment and better access to healthy foods and activity, which should reduce alarming disparities in cardiovascular health. New data demonstrate that maintenance of ideal cardiovascular health into middle age can be remarkably successful in black and white young adults who adopt simple healthy lifestyles.10 Yet if the focus is solely on ideal cardiovascular health, it is possible to miss the forest for the trees. Attaining the 2020 goals will require a concerted effort to improve health factors and health behaviors across the spectrum of cardiovascular health, and in all segments of the population, rather than just a marginal increase in the small proportion (<2%) who have ideal levels of all 7 metrics. The recent studies have understandably taken the easier route of counting numbers of ideal metrics at a single point, without exploring the effect of change in intermediate or poor levels on outcomes. Longitudinal cohort studies have the potential to examine individual changes in these metrics, for better or worse, and the effect on outcomes. For instance, a simple point-score system assigning 0 points for poor, 1 point for intermediate, and 2 points for ideal levels could be a good starting point for monitoring individual levels and changes in the population distribution of cardiovascular health and for examining outcomes. To be sure, this simple point-scoring algorithm ignores differential weighting of risk covariates, but it may prove useful, given that the goal is monitoring, not development of a risk score for clinical use. What can be done to improve cardiovascular health? The concept proposed by Rose to shift the population distribution toward greater health is the key. Despite the apparent difficulties in achieving the goal, there is much to be optimistic about, and opportunities abound for physicians, policy makers, and consumers to support improvements in cardiovascular health. Continued focus through the health care system on meeting primary and secondary prevention targets is critically important, so that individuals at risk can take one step forward from poor to intermediate cardiovascular health. Advocacy will be needed for new public health and social policies to tilt the playing field toward healthier choices, so more individuals can move from intermediate to ideal levels or maintain ideal cardiovascular health. The debate over this year's farm bill, which will set policy for years to come, represents an opportunity for advocacy for cardiovascular health and a healthier food supply for all. Efforts to reduce sodium in the food supply are ongoing on multiple fronts. The AHA has outlined a bold set of strategic programs to improve cardiovascular health and is partnering with the Department of Health and Human Services on the similar Healthy People 2020 goals. Although it is not widely appreciated, the Affordable Care Act contains critically important resources for prevention and health promotion, and these resources must be maintained.11 The Million Hearts initiative12 will also move the population closer to achieving the goals. A good start is for each person to assess his or her own cardiovascular health.13 The nation can, and must, take one step forward toward improved cardiovascular health. Back to top Article Information Corresponding Author: Donald M. Lloyd-Jones, MD, ScM, Department of Preventive Medicine, Northwestern University Feinberg, School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 (dlj@northwestern.edu). Published Online: March 16, 2012. doi:10.1001/jama.2012.361 Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association. References 1. Lloyd-Jones DM, Hong Y, Labarthe D, et al; American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's Strategic Impact Goal through 2020 and beyond. Circulation. 2010;121(4):586-61320089546PubMedGoogle ScholarCrossref 2. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14(1):32-383872850PubMedGoogle ScholarCrossref 3. Rose G. The Strategy of Preventive Medicine. New York, NY: Oxford University Press; 1992 4. Strasser T. Reflections on cardiovascular diseases. Interdiscip Sci Rev. 1978;3(3):225-230Google ScholarCrossref 5. Yang Q, Cogswell ME, Flanders WD, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults [published online March 16, 2012]. JAMA. 2012;307(12):1273-1283Google ScholarCrossref 6. Bambs C, Kip KE, Dinga A, Mulukutla SR, Aiyer AN, Reis SE. Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study. Circulation. 2011;123(8):850-85721321154PubMedGoogle ScholarCrossref 7. Ford ES, Greenlund KJ, Hong Y. Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States [published online January 30, 2012]. Circulation22291126PubMedGoogle Scholar 8. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD.ARIC Study Investigators. Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol. 2011;57(16):1690-169621492767PubMedGoogle ScholarCrossref 9. Roger VL, Go AS, Lloyd-Jones DM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2-e22022179539PubMedGoogle ScholarCrossref 10. Liu K, Daviglus ML, Loria C, et al. Healthy lifestyle through young adulthood and presence of low cardiovascular disease risk profile in middle age [published online January 30, 2012]. Circulation22291127PubMedGoogle Scholar 11. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363(14):1296-129920879876PubMedGoogle ScholarCrossref 12. Frieden TR, Berwick DM. The “Million Hearts” initiative—preventing heart attacks and strokes. N Engl J Med. 2011;365(13):e2721913835PubMedGoogle ScholarCrossref 13. My Life Check. American Heart Association website. http://mylifecheck.heart.org. Accessed February 29, 2012 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Improving the Cardiovascular Health of the US Population

JAMA , Volume 307 (12) – Mar 28, 2012

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American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2012.361
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Abstract

Building on the successful accomplishment of its goals for the last decade, in 2010 the American Heart Association (AHA) announced its new Strategic Impact Goals: “By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.”1 The novel aspect of the 2020 goals is the promotion of “cardiovascular health,” a new, positive approach to prevention of cardiovascular disease (CVD). Seven health behaviors and health factors currently define cardiovascular health: smoking status, body mass index, dietary content, participation in physical activity, and levels of blood pressure, blood glucose, and total cholesterol. To encompass the entire spectrum of cardiovascular health (from optimal to uncontrolled levels), each metric has 3 clinically based strata defined as ideal, intermediate, and poor.1 Two key concepts are central to the development and achievement of the AHA's goals. The first concept was promulgated by Rose,2 who noted that prevention efforts can focus on unhealthy individuals or unhealthy populations. With diseases such as CVD, the majority of events occur in the large proportion of the population with average or only mildly elevated levels of risk factors, rather than in the small subset with marked elevations. Therefore, in addition to “high-risk strategies,” “population strategies” must be used to shift the entire population distribution of risk factors toward more favorable levels. When population strategies are successful, small changes in population mean levels can result in large reductions in disease rates.3 The second concept, introduced by Strasser,4 defines population strategies that prevent risk factor development in the first place: so-called primordial prevention. Once a risk factor has developed, it is difficult to reduce risk back to low levels. Pharmacological and lifestyle interventions for secondary and primary prevention, while effective, will not reduce CVD event rates to levels seen in those who maintain optimal risk factor profiles (ideal cardiovascular health) into middle and older ages. In a report in this issue of JAMA, Yang and colleagues5 examine secular trends in cardiovascular health metrics in the US population over the last 20 years. As seen in other analyses,1,6-9 the prevalence of having all 7 factors at ideal levels was less than 2% and remained similarly low over time. Whereas there were some positive trends in smoking, physical activity, blood pressure, and cholesterol levels, there were alarming trends in the decreasing proportion of adults following 2 or more of the 5 dietary components and increases in the prevalence of obesity and impaired fasting glucose levels.5 Given these trends, it is clear that reaching the AHA 2020 goals will be difficult. However, the data also indicate the critical importance of attempting to shift the population toward greater cardiovascular health. Yang et al report associations between the numbers of ideal cardiovascular health metrics and mortality over 14.5 years. Compared with individuals with 0 or 1 metrics at ideal levels, those with 6 or more metrics at ideal levels had 51%, 76%, and 70% lower adjusted hazards for all-cause, CVD, and ischemic heart disease mortality, respectively. Risk reductions were similar for older ages, both sexes, and all race/ethnicity and educational attainment groups, and having 6 or more ideal metrics was particularly associated with avoidance of premature CVD death. Higher numbers of ideal metrics were even associated with lower hazards for cancer mortality.5 These findings are consistent with recent analyses demonstrating similar marked reductions in short-term mortality7 and 20-year fatal and nonfatal CVD event rates8 with higher numbers of ideal cardiovascular health metrics. Thus, the case for the ideal cardiovascular health construct with regard to important outcome events appears to be settled. Further work is needed to examine outcomes in health-related quality of life and health care expenditures. Why do so few Americans have ideal cardiovascular health? The answer is clear. Data from all of the recent studies indicate that the face of ideal cardiovascular health is a young, educated white woman. The pattern of ideal cardiovascular health is the norm in most infants, but it is lost, sometimes rapidly, during childhood, adolescence, and young adulthood through adoption of adverse health behaviors related to diet, weight, and sedentary lifestyle, particularly in populations with lower socioeconomic status. Thus, the nature of the problem transcends the health care and public health systems, and solutions must also come through improvements in the built environment and better access to healthy foods and activity, which should reduce alarming disparities in cardiovascular health. New data demonstrate that maintenance of ideal cardiovascular health into middle age can be remarkably successful in black and white young adults who adopt simple healthy lifestyles.10 Yet if the focus is solely on ideal cardiovascular health, it is possible to miss the forest for the trees. Attaining the 2020 goals will require a concerted effort to improve health factors and health behaviors across the spectrum of cardiovascular health, and in all segments of the population, rather than just a marginal increase in the small proportion (<2%) who have ideal levels of all 7 metrics. The recent studies have understandably taken the easier route of counting numbers of ideal metrics at a single point, without exploring the effect of change in intermediate or poor levels on outcomes. Longitudinal cohort studies have the potential to examine individual changes in these metrics, for better or worse, and the effect on outcomes. For instance, a simple point-score system assigning 0 points for poor, 1 point for intermediate, and 2 points for ideal levels could be a good starting point for monitoring individual levels and changes in the population distribution of cardiovascular health and for examining outcomes. To be sure, this simple point-scoring algorithm ignores differential weighting of risk covariates, but it may prove useful, given that the goal is monitoring, not development of a risk score for clinical use. What can be done to improve cardiovascular health? The concept proposed by Rose to shift the population distribution toward greater health is the key. Despite the apparent difficulties in achieving the goal, there is much to be optimistic about, and opportunities abound for physicians, policy makers, and consumers to support improvements in cardiovascular health. Continued focus through the health care system on meeting primary and secondary prevention targets is critically important, so that individuals at risk can take one step forward from poor to intermediate cardiovascular health. Advocacy will be needed for new public health and social policies to tilt the playing field toward healthier choices, so more individuals can move from intermediate to ideal levels or maintain ideal cardiovascular health. The debate over this year's farm bill, which will set policy for years to come, represents an opportunity for advocacy for cardiovascular health and a healthier food supply for all. Efforts to reduce sodium in the food supply are ongoing on multiple fronts. The AHA has outlined a bold set of strategic programs to improve cardiovascular health and is partnering with the Department of Health and Human Services on the similar Healthy People 2020 goals. Although it is not widely appreciated, the Affordable Care Act contains critically important resources for prevention and health promotion, and these resources must be maintained.11 The Million Hearts initiative12 will also move the population closer to achieving the goals. A good start is for each person to assess his or her own cardiovascular health.13 The nation can, and must, take one step forward toward improved cardiovascular health. Back to top Article Information Corresponding Author: Donald M. Lloyd-Jones, MD, ScM, Department of Preventive Medicine, Northwestern University Feinberg, School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 (dlj@northwestern.edu). Published Online: March 16, 2012. doi:10.1001/jama.2012.361 Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association. References 1. Lloyd-Jones DM, Hong Y, Labarthe D, et al; American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's Strategic Impact Goal through 2020 and beyond. Circulation. 2010;121(4):586-61320089546PubMedGoogle ScholarCrossref 2. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14(1):32-383872850PubMedGoogle ScholarCrossref 3. Rose G. The Strategy of Preventive Medicine. New York, NY: Oxford University Press; 1992 4. Strasser T. Reflections on cardiovascular diseases. Interdiscip Sci Rev. 1978;3(3):225-230Google ScholarCrossref 5. Yang Q, Cogswell ME, Flanders WD, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults [published online March 16, 2012]. JAMA. 2012;307(12):1273-1283Google ScholarCrossref 6. Bambs C, Kip KE, Dinga A, Mulukutla SR, Aiyer AN, Reis SE. Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study. Circulation. 2011;123(8):850-85721321154PubMedGoogle ScholarCrossref 7. Ford ES, Greenlund KJ, Hong Y. Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States [published online January 30, 2012]. Circulation22291126PubMedGoogle Scholar 8. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD.ARIC Study Investigators. Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol. 2011;57(16):1690-169621492767PubMedGoogle ScholarCrossref 9. Roger VL, Go AS, Lloyd-Jones DM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2-e22022179539PubMedGoogle ScholarCrossref 10. Liu K, Daviglus ML, Loria C, et al. Healthy lifestyle through young adulthood and presence of low cardiovascular disease risk profile in middle age [published online January 30, 2012]. Circulation22291127PubMedGoogle Scholar 11. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363(14):1296-129920879876PubMedGoogle ScholarCrossref 12. Frieden TR, Berwick DM. The “Million Hearts” initiative—preventing heart attacks and strokes. N Engl J Med. 2011;365(13):e2721913835PubMedGoogle ScholarCrossref 13. My Life Check. American Heart Association website. http://mylifecheck.heart.org. Accessed February 29, 2012

Journal

JAMAAmerican Medical Association

Published: Mar 28, 2012

Keywords: cardiovascular system

References