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Million Hearts® and Sodium: Best Practices and Opportunities

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1 Million Hearts® and Sodium: Best Practices and Opportunities
August 22, 2013 2:00pm - 3:00pm The CDC Million Hearts® Collaboration encourages states to get involved with Million Hearts®. The CDC Million Hearts Collaboration created a State Engagement Guide to support states in their Million Hearts efforts. The Guide includes information on the initiative as well as ways to support Million Hearts®, lessons learned and key recommendations, workshop descriptions and examples, resources, and information on how the Collaboration organizations can assist you in working with Million Hearts®.

2 Welcome & Overview Jill Birnbaum, JD Vice President, State Advocacy & Public Health American Heart Association

3 Agenda Time Agenda Item / Topic Speaker / Facilitator 3:00
Welcome, Overview Jill Birnbaum, JD, Vice President, State Advocacy & Public Health, American Heart Association 3:05 AHA Sodium Conference Highlights Emily Ann Miller, Emily Ann Miller, MPH, RD, National Program Lead, Sodium Reduction Initiative, American Heart Association 3:20 Sodium Intake in Populations: Assessment of Evidence, 2013 IOM Report Cheryl Anderson, Cheryl A. M. Anderson, PhD, MPH, MS, Associate Professor, Department of Family and Preventive Medicine, University of California San Diego School of Medicine 3:35 Future Direction of Procurement Policy Laurie Whitsel, Ph.D., Director of Policy Research, American Heart Association 3:45 Million Hearts Support and Engagement John Clymer, Executive Director, National Forum for Heart Disease and Stroke Prevention 3:55 Q and A Facilitated by Jill Birnbaum, JD, Vice President, State Advocacy & Public Health, American Heart Association Welcome to the Million Hearts® and Sodium: Best Practices and Opportunities Webinar. This webinar is hosted by the American Heart Association and the National Forum for Heart Disease and Stroke Prevention. You will learn how your organization can address sodium reduction in the United States and work with Million Hearts®. Decreasing sodium intake of the population is one of the objectives under Goal 1: Prevent and control high blood pressure from the Million Hearts Initiative Strategic Framework. This afternoon you will hear highlights from the American Heart Association's recent sodium conference from Emily Ann Miller, National Program Lead, Sodium Reduction Initiative with the American Heart Association. You will then learn about and discuss the Institute of Medicine's 2013 report "Sodium Intake in Populations: Assessment of Evidence” from Dr. Cheryl A. M. Anderson, Associate Professor in the Department of Family and Preventive Medicine with the University of California San Diego School of Medicine. You will then hear about the future direction of procurement policies from Dr. Laurie Whitsel, Director of Policy Research with the American Heart Association The final presentation is from John Clymer, Executive Director of the National Forum for Heart Disease and Stroke Prevention who will discuss ways to support and engage in Million Hearts activities. Lastly, there will be a question and answer session at the end of all the presentations. You will submit questions online. This is private and not viewable by other participants. Please direct your questions to All Panelists and then hit the submit button. I will now turn the program over to Emily to begin.

4 AHA Sodium Conference Highlights
Emily Ann Miller, MPH, RD National Program Lead, Sodium Reduction Initiative American Heart Association

5 Date: June 19-20, 2013; Arlington, VA
Attendees: 140 stakeholders from various sectors Purpose: Create an interactive and collaborative environment to discuss the status and future implications of reducing sodium in the food supply and to identify opportunities for stakeholder collaboration. Not intended to debate the appropriate level of sodium intake, i.e. 2,300mg vs. 1,500mg, rather, to coalesce around our common ground June 19-20, 2013; Arlington, VA. The conference was being planned for at least a year before its date. Invitation-only, due to venue space limitations and desire to promote an intimate environment, where everyone is a participant; media not invited 140 stakeholders engaged in research and development; food ingredients, manufacturing, and retail; foodservice; regulatory and legislative activities; public health initiatives; and monitoring and surveillance Purpose: create an interactive and collaborative environment to discuss the status and future implications of reducing sodium in the food supply. We wanted an opportunity for dialogue and discussion, where people could learn from each others’ successes and challenges and identify opportunities for collaboration. It was valuable to have stakeholders from various sectors at the table so we could share current data and updates, understand each other’s perspectives and challenges, and identify ways to work together to overcome the challenges. Not intended to debate the appropriate level of sodium intake, i.e. 2,300mg vs. 1,500mg, rather, to coalesce around our common ground which is that Americans’ current intakes of 3,400mg/day are higher than any public health recommendation and need to be reduced.

6 Planning Committee Elliott Antman, MD, Brigham and Women’s Hospital and Harvard Medical School – AHA President-Elect Larry Appel, MD, MPH, Johns Hopkins University – Chair, Sodium Reduction Advisory Task Force Doug Balentine, PhD, Unilever – Chair, Industry Nutrition Advisory Panel Rachel Johnson, PhD, MPH, RD, University of Vermont – Chair, Nutrition Committee Lyn Steffen, PhD, MPH, RD, University of Minnesota – EPI Council Liaison to Nutrition Committee AHA staff worked with a planning committee to develop the conference agenda and select speakers. The planning committee included experts from academia, healthcare, public health, and industry. All of them hold leadership roles on AHA volunteer committees.

7 Objectives Assess the current status and future implications of efforts to reduce sodium in the food supply. Leverage expertise from different disciplines to identify and evaluate sodium reduction strategies; address opportunities and challenges. Discuss ways to translate sodium reduction strategies into practical application. Identify short-term and long-term goals sodium reduction goals and factors that impact timelines for achieving these goals. Identify collaboration opportunities among stakeholders. Identify metrics and methodologies for evaluating the collective impact of sodium reduction efforts on the food supply and on health outcomes. We hope that this conference will help attendees learn more about sodium reduction strategies that have been tried or may be options for future implementation, and how they can translate those strategies into practical application. We also want to identify short- and long-term goals for sodium reduction, and get an idea of the timelines for both types of goals. We also need to know what data we need to collect that will tell us whether we’ve been successful.

8 Agenda Plenary Sessions
Science behind sodium reduction and public health recommendations Measurement of sodium intakes Consumer knowledge, attitudes, and behaviors re: sodium Food technology and solutions for sodium reduction Food industry experiences and perspectives Potential policy and education strategies for sodium reduction Breakout sessions Agenda included plenary sessions with presentations by topic experts, panel discussions, and breakout sessions. The presentations focused on topics on this slide, such as… The plenary sessions were held on Day 1 and the morning of Day 2; the rest of the time on Day 2 was devoted to breakout sessions.

9 Breakout Sessions Opportunity for participants to contribute their expertise and thoughts Intended to identify areas that are ripe for further investigation and possibly, future action 4 facilitator-led breakout groups Major takeaways from presentations; key determinants of success; guiding principles for future actions; most promising solutions and how to overcome their potential barriers; roles for various sectors The breakout sessions were an opportunity for each participant to contribute his or her expertise and thoughts. The purpose of these groups was not to emerge with iron-clad recommendations about strategies to reduce sodium intake, but instead to identify areas that are ripe for further investigation and potential future action. We had 4 groups, each led by a facilitator, and all 4 facilitators led their groups through the same breakout discussion guide. Groups discussed several topics, starting with the major takeaways from the plenary sessions. Determinants of success – what elements must be present in strategies to reduce sodium intakes and sodium in the food supply? Examples: multi-sector collaboration; win-win for industry and consumers; realistic solutions Guiding principles for evaluating and recommending alternative actions and/or decisions to reduce sodium Examples: evidence-based; measurability (both short and long term); transparency Roles for the various sectors – academia, health professionals, public health, government, industry, retailers, chefs/culinary

10 Themes from Breakout Sessions
Complexity Commitment Collaboration Communication Consistency Common Ground Several themes emerged from the breakout discussions, all of which happen to begin with the letter C.

11 Themes from Breakout Sessions
Complexity Sodium reduction involves much more than just taking out the salt Commitment It will be a long term effort; some progress has been made but there is much more work ahead; lowering sodium in the food supply is critical Collaboration It is imperative to have simultaneous, multi-sector efforts Communication/Consistency We need simple, positive, consistent messages that are culturally-appropriate and come from multiple voices Common Ground Incorporate sodium as part of a total health/total diet approach and reap multiple benefits for cardiovascular health Complexity: Sodium reduction is here to stay and will be a long-term effort because it is complex and challenging, (and there are unique challenges of packaged goods vs. restaurants/foodservice), more complicated than just adjusting flavor, and we must be careful to avoid unintended consequences Commitment: There is optimism about the progress that has been made but there’s still a lot more work ahead (want to see a drop in consumer sodium intakes) Commitment: Lowering sodium in the food supply is critical Key question: Do we pursue technologies that decrease sodium but still make food taste the same, or do we actually lower salt taste preferences? Stealth reductions are effective and should continue We need more sodium-lowering technologies – opportunity to innovate Level playing field is needed Collaboration: It is imperative to have simultaneous, multi-sector efforts Communication/Consistency: To motivate consumer behavior change and education, there is a need for clear, simple, consistent, positive, messages that are culturally-appropriate/relevant and come from multiple voices (AHA, gov’t, industry, others) Common ground: We should incorporate sodium as part of a “total health/total diet” approach where healthy is the default; there is also synergy in this kind of approach – reducing kcals through increasing K+-rich fruits/veg should achieve not only population-wide Na reduction but other health benefits as well Others: --The current focus of the political environment (FDA) is on promoting voluntary approaches to sodium reduction, not mandatory approaches, and procurement policies were mentioned several times has having a lot of promise --There is value in the collecting and sharing data to direct and re-direct our efforts, need more systematic and transparent ways of sharing data

12 Conference Proceedings
Proceedings to be published in an AHA journal Estimated timing: January 2014 THANK YOU! Emily Ann Miller, MPH, RD Complexity: Sodium reduction is here to stay and will be a long-term effort because it is complex and challenging, (and there are unique challenges of packaged goods vs. restaurants/foodservice), more complicated than just adjusting flavor, and we must be careful to avoid unintended consequences Commitment: There is optimism about the progress that has been made but there’s still a lot more work ahead (want to see a drop in consumer sodium intakes) Commitment: Lowering sodium in the food supply is critical Key question: Do we pursue technologies that decrease sodium but still make food taste the same, or do we actually lower salt taste preferences? Stealth reductions are effective and should continue We need more sodium-lowering technologies – opportunity to innovate Level playing field is needed Collaboration: It is imperative to have simultaneous, multi-sector efforts Communication/Consistency: To motivate consumer behavior change and education, there is a need for clear, simple, consistent, positive, messages that are culturally-appropriate/relevant and come from multiple voices (AHA, gov’t, industry, others) Common ground: We should incorporate sodium as part of a “total health/total diet” approach where healthy is the default; there is also synergy in this kind of approach – reducing kcals through increasing K+-rich fruits/veg should achieve not only population-wide Na reduction but other health benefits as well Others: --The current focus of the political environment (FDA) is on promoting voluntary approaches to sodium reduction, not mandatory approaches --There is value in the collecting and sharing data to direct and re-direct our efforts, need more systematic and transparent ways of sharing data

13 Sodium Intake in Populations: Assessment of Evidence, 2013 IOM Report
Cheryl Anderson, PhD, MPH, MS Associate Professor, Department of Family and  Preventive Medicine University of California San Diego School of Medicine

14 Sodium Intake in Populations: Assessment of Evidence

15 Statement of Task Evaluate the results, study design, and methodological approaches to assessing the relationship between sodium and health outcomes in the literature since 2003. Evaluate potential benefits/adverse impacts of reduced population sodium intake (i.e. 1,500 – 2,300 mg/day) in the population generally and for population subgroups (those with hypertension and prehypertension, those 51 years of age and older, African Americans, and those with diabetes, chronic kidney disease, and congestive heart failure). Comment on the implications for population-based strategies to reduce sodium intake. Identify data and methods gaps and suggest ways to address them.

16 Step 1: Literature Search

17 Step 2: Review and Evaluation of Studies
Criteria: Generalizability to the populations of interest General U.S. population Subgroups (hypertensive/prehypertensive, 51 years and older, African American, those with diabetes, chronic kidney disease, and congestive heart failure) Methodological appropriateness Study design Quantitative measures of dietary sodium intake Confounder adjustment Number and consistency of relevant studies available

18 Factors that Impacted Evaluation
Variability in the types and quality of measures used in observational studies and clinical trials Lack of consistency among studies in the methods used for defining sodium intakes at both high and low ends of the range of typical intakes Extreme variability in intake levels between and among population groups precluded the committee from establishing a “healthy” intake range. Committee could consider sodium intake levels only within the context of each individual study.

19 Overarching Findings Many populations evaluated were outside the US
included groups that consumed mean levels of sodium much higher than the average amount consumed by adults in the US The quantity and quality of relevant studies was less than optimal limitations associated with the quantitative measures of sodium intake potential for spurious findings related to incorrect measurement and reverse causality Variability in the types and quality of measures used, so that measures could not be reliably calibrated across studies

20 Findings and Conclusions
General Population Finding 1: Results from studies linking dietary sodium intake with direct health outcomes were highly variable in methodological quality, particularly in assessing sodium intake. The range of limitations included over- or under-reporting of intakes or incomplete collection of urine samples. In addition, variability in data collection methodologies limited the committee’s ability to compare results across studies. Conclusion 1: Given the methodological flaws and limitations, when considered collectively, the evidence indicates a positive relationship between higher levels of sodium intake and risk of CVD. This evidence is consistent with existing evidence on blood pressure as a surrogate indicator of CVD risk.

21 General Population Finding 2: Evidence from studies on direct health outcomes was insufficient and inconsistent regarding an association between sodium intake below 2,300 mg per day and benefit or risk of CVD outcomes (including stroke and CVD mortality) or all-cause mortality in the general US population. Conclusion 2: Evidence from studies on direct health outcomes is inconsistent and insufficient to conclude that lowering sodium intakes below 2,300 mg/day either increases or decreases risk of CVD outcomes (including stroke and CVD mortality) or all-cause mortality in the general U.S. population.

22 Population Subgroups Finding 1: Evidence from multiple randomized controlled trials (RCTs) that were conducted by a single investigative team indicated that low sodium intake (e.g., to 1,840 mg/day) may lead to greater risk of adverse events in congestive heart failure (CHF) patients with reduced ejection fraction and who are receiving certain aggressive therapeutic regimens. This association also is supported by one observational study where low sodium intake levels in patients with CVD and diabetes were associated with higher risk of CHF events. Conclusion 1: Evidence suggests that low sodium intakes may lead to higher risk of adverse events in mid- to late-stage CHF patients with reduced ejection fraction and who are receiving aggressive therapeutic regimens. Because these therapeutic regimens were very different than current standards of care in the US, the results may not be generalizable. Similar studies in other settings and using regimens more closely resembling those in standard U.S. clinical practice are still needed.

23 Population Subgroups Finding 2: Data among prehypertensive participants from two related studies provided some evidence suggesting a continued benefit of lowering sodium intake in these patients down to 2,300 mg per day (and lower, although based on small numbers in the lower range). No evidence was found for benefit and some evidence suggesting risk of adverse health outcomes associated with sodium intake levels in ranges approximating 1,500 to 2,300 mg per day in other disease-specific population subgroups (those with diabetes, chronic kidney disease (CKD), or pre-existing CVD).

24 Population Subgroups Finding 2: In addition to inconsistencies in sodium intake measures, methodological flaws included the possibility of confounding and reverse causality. No relevant evidence was found on health outcomes for other population subgroups considered (i.e., persons 51 years of age and older, and African Americans). In studies that explored interactions, race, age, or the presence of hypertension or diabetes did not change the effect of sodium on health outcomes.

25 Population Subgroups Conclusion 2: With the exception of CHF patients, the current body of evidence addressing the association between low sodium intake and health outcomes in the population subgroups considered is limited. The evidence available is inconsistent and limited in its approaches to measuring sodium intake. The evidence also is limited by small numbers of health outcomes and the methodological constraints of observational study designs, including the potential for reverse causality and confounding.

26 Population Subgroups Conclusion 2: While the current literature provides some evidence for adverse health effects of low sodium intake among individuals with diabetes, CKD, or pre-existing CVD, the evidence on both the benefit and harm is not strong enough to indicate that these subgroups should be treated differently from the general U.S. population. Thus, the evidence on direct health outcomes does not support prior recommendations to lower sodium intake within these subgroups to, or even below, 1,500 mg/day.

27 Implications for Population-based Strategies
The available evidence on associations between sodium intake and direct health outcomes is consistent with population-based efforts to lower excessive dietary sodium intakes, but it is not consistent with efforts that encourage lowering of dietary sodium in the general population to 1,500 mg/day. The evidence reviewed also suggests that dietary sodium intake may affect heart disease risk through pathways in addition to blood pressure.

28 Implications for Population-based Strategies
Further research may shed more light on the association between lower (1,500 to 2,300 mg) levels of sodium and health outcomes in the general population and subpopulations.  The committee was not asked to draw conclusions about a specific target range of dietary sodium.  Other factors also precluded specifying a such range. These included methodologic problems in assessing sodium intake and difficulty calibrating those measures across different approaches to measuring intake and different study designs.

29 Committee BRIAN L. STROM (Chair), University of Pennsylvania CHERYL A.M. ANDERSON, University of California San Diego JAMY ARD, Wake Forest Baptist Health KIRSTEN BIBBINS-DOMINGO, University of California San Francisco NANCY R. COOK, Brigham & Women’s Hospital MARY KAY FOX, Mathematica Policy Research NIELS GRAUDAL, Copenhagen University Hospital JIANG HE, Tulane University JOACHIM IX, Veterans Affairs San Diego Healthcare System STEPHEN E. KIMMEL, University of Pennsylvania ALICE H. LICHTENSTEIN, Tufts University MYRON WEINBERGER, Indiana University

30 Future Direction of Procurement Policy
Laurie Whitsel, PhD Director of Policy Research American Heart Association

31 The AHA’s 2010-2014 Strategic Policy Agenda Focuses on Achieving our 2020 Goals
Decrease deaths from CVD and Stroke Improve the overall CV health of Americans The current agenda focuses on areas that will reach the 2020 goal of decreasing death from CVD and stroke, and improve the overall cardiovascular health of Americans.

32 Procurement Increasing attention on the importance of creating healthier work environments and healthier food options to the public in different settings.

33 Procurement Potential Environments government buildings
hospital systems college/university campuses Schools/child care centers assisted living facilities faith-based organizations private corporations theme parks/resorts prisons non-profit organizations

34 Procurement Targets for nutrition standards for food and beverage procurement Vending machines Cafeterias Concession stands Meetings/conferences Organizational events

35 Procurement Numerous existing model standards AHA
HHS/Federal Government Municipal governments National Alliance for Nutrition and Activity Alliance for a Healthier Generation

36 Forthcoming AHA Paper Will address such issues as:
Existing model standards Barriers to implementation Legal issues Case studies Importance of Evaluation

37 The Future of Procurement Policy
Where do we go from here?

38 Procurement A relatively new area of policy development
Will require an assessment of the impact of the numerous existing policies across the U.S. Consistent evaluation for Purchasing behavior Availability of healthy food in purchasing Affordability/Cost Issues Health impact Levels of adoption Industry response

39 Million Hearts® Support and Engagement
John Clymer Executive Director National Forum for Heart Disease and Stroke Prevention

40 The Million Hearts® Initiative
Goal: Prevent 1 million heart attacks and strokes in 5 years National initiative co-led by CDC and CMS Partners across federal, state, and local government and private organizations Million Hearts® is a national initiative to prevent 1 million heart attacks and strokes in the U.S. by Launched by the U.S. Department of Health and Human Services (HHS) in September 2011, it aligns existing efforts, as well as creates new programs, to improve health across communities and help Americans live longer, more productive lives. The Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS), co-leaders of Million Hearts® within HHS, are working alongside federal, state, and local entities and private-sector organizations to make a long-lasting impact against cardiovascular disease.

41 CDC Million Hearts® Collaboration
American Heart Association National Forum for Heart Disease & Stroke Prevention Association of State and Territorial Health Officials National Association of City County Health Officials National Association of Chronic Disease Directors The American Heart Association and the National Forum for Heart Disease and Stroke Prevention are co-leading the CDC Million Hearts Collaboration, which includes the Association of State and Territorial Health Officials, the National Association of Chronic Disease Directors with its Cardiovascular Health Council, and the National Association of County and City Health Officials. The goals of the Collaboration are to coordinate and disseminate priority messages and strategies related to Million Hearts, as well as encourage new stakeholder engagement.

42 Key Components Improve care for people who need treatment by encouraging a targeted focus on the “ABCS” Empower Americans to make healthy choices such as not using tobacco and reducing sodium and trans fat consumption Million Hearts® is seeking participation from organizations interested in targeting improvements in clinical preventive practice and/or community prevention. You can do this by implementing programs, projects or initiatives for the following: Improve care for people who do need treatment by encouraging a targeted focus on the “ABCS”—Aspirin for people at risk, Blood pressure control, Cholesterol management, and Smoking cessation—which address the major risk factors for cardiovascular disease and can help to prevent heart attacks and strokes. Empower Americans to make healthy choices such as preventing tobacco use and reducing sodium and trans fat consumption. This can help reduce the number of people who need medical treatment such as blood pressure or cholesterol medications to prevent heart attacks and strokes.

43 Actions You Can Take Align existing initiatives and programs with Million Hearts® goals Convene partners, stakeholders, and policy makers for Million Hearts® for planning purposes Share success stories on Million Hearts® Actions organizations can take to advance Million Hearts® include the following: Align existing initiatives and programs with Million Hearts® goals, for example, using patient and provider reminder systems and matching your policy agenda to Million Hearts goals. Convene partners, stakeholders, and policy makers for Million Hearts® for planning purposes (in a few minutes I will share a new resource created by the Collaboration on State Engagement and working with key partners). And Share success stories on Million Hearts® through Community Commons, through your own organization newsletters and other communications channels.

44 Ways to Use Million Hearts® to Achieve Your 0rganizations goals
Join Community Commons – Connect, Share, and Collaborate on Million Hearts® Activities Become a Million Hearts® Partner Pledge Support on the Million® Hearts Website – Be One in a Million Hearts® Ways to Use Million Hearts® to Achieve Your 0rganizations goals Community Commons Many organizations at all levels are hearing about Million Hearts® and are committing to various Million Hearts® Goals. Helping these organizations find each other is a main function of Community Commons (http://www.communitycommons.org/). Community Commons is a web-based interactive mapping, networking, and learning utility where you can highlight your organization’s Million Hearts® activities; share ideas and best practices; and collaborate with other organizations in your community. Individuals can register and join the Million Hearts® Group profile. They can also work with their organizations to create an Initiative Profile so that their organization is recognized as part of the Million Hearts® cohort on the Map of the Movement. We encourage you to post your Million Hearts® activities, questions, and comments on Community Commons. Partners Million Hearts® Partners are organizations that make a formal commitment to the initiative. This formal commitment includes concise and specific action steps that the organization proposes to conduct in support of the Million Hearts® initiative, with explicit timelines for completion, measurable results, and rationale for how it will help support the goal. Partners from across the public and private health sectors are supporting Million Hearts® through a wide range of activities. Organizations interested in becoming Million Hearts® Partners are asked to review their mission and portfolio, and identify specific steps they will take to support the Million Hearts® goal. States are encouraged to become official Million Hearts® partners, but it is not required. Many states are doing great work in support of Million Hearts® and may not be listed on the website for various reasons. Pledging Support Pledging your support for Million Hearts® means you are promising to help achieve a greater impact on cardiovascular health throughout the United States. Any individual or organization can pledge by visiting the Be One in a Million Hearts® tab on the Million Hearts® website, specifying individual or choosing the appropriate organization type, and filling in the fields and clicking ‘Count Me In'. Through this process you will be added to the overall number of Million Hearts® Pledges. CDC will not contact you for information about your activities. However, this information provides the Million Hearts® Team with the location of your efforts and is showcased on a map of individuals and organizations who pledged under the Be One in a Million Hearts® tab.

45 State Engagement Guide
Includes information on the initiative Ways to use Million Hearts® to achieve your organization’s goals Lessons learned and key recommendations, Workshop descriptions Examples, resources, and information on how the Collaboration organizations can assist in working with Million Hearts® I wanted to also share with you a new resource developed by the CDC Million Hearts® Collaboration. The Collaboration created a State Engagement Guide to support states in their Million Hearts efforts. The Guide includes information on the initiative as well as ways to support Million Hearts®, lessons learned and key recommendations, workshop descriptions and examples, resources, and information on how the Collaboration organizations can assist in working with Million Hearts®. While states were the intended audience for this guide, there is useful information for organizations to reference with Million Hearts® engagement. (This is the last slide – transition to Jill for Q and A)

46 National Forum Members / Million Hearts® Partners
American College of Cardiology National Association of County and City Health Officials American Heart Association National Heart, Lung, and Blood Institute American Medical Group Foundation National Lipid Association Association of Black Cardiologists, Inc. Preventive Cardiovascular Nurses Association Association of State and Territorial Health Officials U.S. Department of Health and Human Services Centers for Disease Control and Prevention U.S. Department of Veterans Affairs, Ischemic Heart Disease Quality Enhancement Research Initiative Health Resources and Services Administration Indian Health Service U.S. Food and Drug Administration, Office of Women's Health National Association of Chronic Disease Directors WomenHeart YMCA 19 National Forum member organizations are also Million Hearts partners

47 Questions & Answers It is now time for the question and answer session. Please submit questions online. This is private and not viewable by other participants. Please direct your questions to All Panelists and then hit the submit button. I will then read the questions and seek a panelists for response. Jill Birnbaum, JD Vice President, State Advocacy & Public Health American Heart Association

48 AHA Activities I wanted to also share with you a new resource developed by the CDC Million Hearts® Collaboration. The Collaboration created a State Engagement Guide to support states in their Million Hearts efforts. The Guide includes information on the initiative as well as ways to support Million Hearts®, lessons learned and key recommendations, workshop descriptions and examples, resources, and information on how the Collaboration organizations can assist in working with Million Hearts®. While states were the intended audience for this guide, there is useful information for organizations to reference with Million Hearts® engagement. (This is the last slide – transition to Jill for Q and A)

49 Thank You! For more information, please visit millionhearts.hhs.gov
Thank you for attending the Webinar today. You will receive a short survey as you exit.


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