1. What is the data telling us?

2. 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%

3. 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

4. (NHANES : 1999-2004). Source: NCHS and NHLBI. Extent of awareness, treatment and control of high blood pressure by age

5. (NHANES: 1999-2004). Source: NCHS and NHLBI. Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity

6. Diabetes Prevalence in Texas, 2007 BRFSS Race/ethnic groupAge GroupPrevalence White18 to 443.0% African-American18 to 443.7% Hispanic18 to 446.8% Other18 to 443.8% White45 to 6410.9% African-American45 to 6417.6% Hispanic45 to 6420.2% Other45 to 6421.1%

7. Prevalence of Prediabetes or DM, NHANES US AgePreDMPre or DM 20 to 3917.9%21.1% 40 to 5930.6%47.0% 60 to 7436.8%66.7%

8. 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

9. 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)

10. 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

11. Clinical Preventive ServicesCPBCETotal Discuss daily aspirin usemen 40+, women 50+ Childhood immunizations Smoking cessation advice and help to quitadults 555555 555555 10 Alcohol screening and brief counselingadults459 Colorectal cancer screeningadults 50+ Hypertension screening and treatmentadults 18+ Influenza immunizationadults 50+ Vision screeningadults 65+ 45434543 43454345 8 Cervical cancer screeningwomen Cholesterol screening and treatmentmen 35+, women 45+ Pneumococcal immunizationsadults 65+ 453453 324324 7 High Value Preventive Services

12. 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

13. What can we do about it? Make healthier choices the easier choices More convenient Lower cost More access More support

14. 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

15. 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

16. 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.

17. 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 BP mm Hg 2 3 5 Reduction in BP mm Hg 2 3 5 % Reduction in Mortality Reduction in BP After intervention Before intervention Stroke CHD Total -6 -4 -3 -8 -5 -4 -14 -9 -7

18. Copyright ©2006 American Heart Association Appel, L. J. et al. Hypertension 2006;47:296-308 Mean systolic BP changes in the DASH-Sodium trial

19. Relative Risk of Developing CHD vs. Systolic Blood Pressure Systolic Blood Pressure Neaton JD. Arch Int Med 1992; 152:56-64.

20. Reduce adult obesity HP 2010 goal 15%

21. Reduce adult obesity, Texas, 2007 HP 2010 goal 15%

22. Adult obesity, Texas, 2007 HP 2010 goal 15%

23. Reduce youth obesity, YRBS HP 2010 goal 5%

24. Reduce youth obesity Texas 2007 YRBS HP 2010 goal 5%

25. Increase adult physical activity HP 2010 goal 50%

26. Increase adult physical activity, Texas, 2007 HP 2010 goal 50%

27. Adult adequate physical activity, Texas, 2007 HP 2010 goal 50%

28. Increase youth physical activity, YRBS HP 2010 goal 85%

29. Increase youth physical activity, Texas 2007 YRBS HP 2010 goal 85%

30. Reduce adult smoking, 2007 BRFSS HP 2010 goal 12%

31. Reduce adult smoking – Texas 2007 BRFSS HP 2010 goal 12%

32. Reduce youth tobacco use, YRBS HP 2010 goal 16%

33. Reduce Texas youth smoking 2007 YRBS HP 2010 goal 16%

34. 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%

35. 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

36. 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/

37. 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