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%
Data from the Texas CVD council
Heart disease deaths 2004 includes: CHF, hypertensive heart dz, vavular dz
Hospitalizations 2005 heart includes CHF

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

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

6. Diabetes Prevalence in Texas, 2007 BRFSS
Race/ethnic group
Age Group
Prevalence
White
18 to 44
3.0%
African-American
3.7%
Hispanic
6.8%
Other
3.8%
45 to 64
10.9%
17.6%
20.2%
21.1%

7. 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%

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.
At least 54 million U.S. adults age 20 and older have pre-diabetes, which independently raises the risk of developing type 2 diabetes and cardiovascular disease. 
It is important to note that progression to diabetes among people with pre-diabetes is not inevitable.
The NIDDK-funded Diabetes Prevention Program (DPP) clinical trial showed us that people who lost 5 to 7 percent of their body weight by making healthy food choices and being physically active 30 minutes a day, 5 days a week reduced the onset of type 2 diabetes by 58%. This powerful reduction in risk was found in all subgroups, including men and women, ethnic groups at high risk, women with a history of GDM, and people age 60 and older.
In fact, participants over the age of 60—who as a group have a nearly 20 percent prevalence of diabetes—reduced their development of diabetes by 71%.
Reference
National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general information and national estimates on diabetes in the United States, Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 2005.
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 Services
High Value Preventive Services
Clinical Preventive Services
CPB CE
Total
Discuss daily aspirin use—men 40+, women 50+ Childhood immunizations Smoking cessation advice and help to quit—adults
5 5 5 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+ 8
Cervical cancer screening—women Cholesterol screening and treatment—men 35+, women 45+ Pneumococcal immunizations—adults 65+
4 5 3
3 2 4 7

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: “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
Living conditions
Family, social
Community
Environment, Policies

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, 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 with a 50% reduction in sodium
working with appropriate partners to educate consumers about the benefits of long-term, moderate reductions in sodium intake;

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
After intervention
Before intervention
Reduction in BP
Reduction in BP
mm Hg 2 3 5
% Reduction in Mortality
Stroke CHD Total
Stamler J. Hypertension
1991;17:I-16–I-20.

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

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

20. Reduce adult obesity HP 2010 goal 15%
Report from the CDC, 31 Oct 08, on annual incidence of diagnosed diabetes. About ¼ of diabetics have not been diagnosed.
Texas adults without diabetes have 1 per 100 each year get diagnosed in , more than doubling in a decade.
Texas diabetes prevalence in adults is about 10%.
Factors associated with an increased risk for diabetes included older age, lower educational attainment, physical inactivity, obesity, weight gain, and being categorized in a racial/ethnic minority population (3). Of these factors, obesity has been identified as a major risk factor in the increasing incidence of diabetes (3); the growth in diabetes prevalence has been concomitant with growth in obesity prevalence (7).

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%
Source:
YRBSS
Students who are at or above the 95th percentile for Body Mass Index (BMI).

24. Reduce youth obesity Texas 2007 YRBS
Source:
YRBSS
Students who are at or above the 95th percentile for Body Mass Index (BMI).
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%
Source: data for US is not yet available.
The question for 2007 and previous years are not strictly comparable because it was changed from
Students who exercised or participated in physical activities that made them sweat or breathe hard for 20 minutes or more on three or more of the past seven days To
Percentage of students who were physically active for a total of at least 60 minutes per day on five or more of the past seven days.

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%
Source:
BRFSS
Current smokers

32. Reduce youth tobacco use, YRBS
HP 2010 goal 16%
Source:
YRBSS
Youth data for US for 2007 are not yet available
US data --
HP goal --

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%
BRFSS
Aspirin 36%

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

37. Review CVD Environmental change and behavior change
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