1. 0 AHA Guide for Improving Cardiovascular Health at the Community Level, 2013 Update: A Statement for Public Health Practitioners, Healthcare Providers, and Health Policy Makers Pearson TA, Palaniappan LP, Artinian NT, Carnethon MR, Criqui MH, Daniels SR, Fonarow GC, Fortmann SP, Franklin BA, Galloway JM, Goff DC Jr, Heath GW, Holland Frank AT, Kris-Etherton PM, Labarthe DR, Murabito JM, Sacco RL, Sasson C, Turner MB; on behalf of the American Heart Association Council on Epidemiology and Prevention.

2. The AHA Community Guide Conceptual Framework for Heart Disease and Stroke Prevention Optimal Behaviors Targeted for Population-Wide Change Intervention Goals, Recommendations, and Current Programs © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

3. 2020 Impact Goal By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%. (Circulation. 2010;121:586-613.) © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

4. Goals and Objectives Provide a comprehensive inventory of evidence- based goals, strategies, and recommendations for cardiovascular disease (CVD) and stroke prevention that can be implemented on a community level. © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

5. Improves Upon the 2003 AHA Community Guide 1)Incorporates new evidence for community interventions gained over the last decade. 2)Expands the target audience to include a broader range of community advocates. 3)Aligns with the concepts and terminology of the AHA 2020 Impact Goals. 4)Recognizes the contributions of new public and private sector programs involving community interventions. © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

6. Complements Existing CVD and Community Guidelines Public health strategies can preserve optimal levels of cardiovascular health factors from childhood throughout the life course or shift the entire population distribution of cardiovascular risk to lower levels. This public health approach yields lifelong benefits in terms of good health and reduced healthcare costs. The AHA Community Guide complements existing guidelines that target individuals, healthcare providers, and communities. The AHA Community Guide provides a comprehensive and up-to-date review of community approaches for CVD prevention. © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

7. Interventions for Population-Wide Health Promotion: Health Impact Pyramid (Frieden TR. Am J Public Health. 2010;100:590-595.) © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

8. Conceptual Framework at a Community Level Optimal behaviors Community setting (Pearson et al. Circulation. 2003;107: 645-651) © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

9. Table 1. Behaviors Targeted to Improve Cardiovascular Health at the Community Level and the Prevalence of Optimal Levels in the U.S. Adult Population. Optimal Behaviors* Prevalence in U.S. Adults with Optimal Behaviors No Tobacco Reduce Tobacco Use73% are nonsmokers Reduce Exposure to Environmental Tobacco Smoke -- Healthy Dietary Practices Approximately 1% meet 4-5 of 7 healthy dietary recommendations BMI <25kg/m 2 (Appropriate caloric balance for age, gender, height and physical activity) 33% have a BMI less than 25 kg/m 2 * Optimal refers to levels associated with lower risk for developing cardiovascular disease. Example: © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

10. Table 2. Systematic Reviews/ Evidence Summaries with Recommendations for Optimal Behaviors at the Community Level Optimal BehaviorsReview/SummaryRecommendation No Tobacco Reduce Tobacco Use Surgeons General Reports USPSTF Institute of Medicine (IOM) Report on Tobacco Complete cessation for individuals Reductions in prevalence of smoking to level where public health impact is minimal Reduce Exposure to Environmental Tobacco Smoke Surgeon General Reports IOM Report on Tobacco Curtail all sources of involuntary exposure to environmental tobacco smoke Healthy Dietary Practices CaloriesAHA 2020 Impact Goals AHA Diet and Lifestyle Recommendations AHA Obesity Guidelines 2010 U.S. Dietary Guidelines Women: 1,600 to 2,400 calories per day Men: 2,000 to 3,000 calories per day Calorie ranges depend on age and physical activity level. Balance calorie intake and physical activity to achieve or maintain a healthy body weight. Example: © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

11. Goals, Recommendations, and Current Programs The intervention goals and recommendations promote lifestyle and behavior change at both the individual and community levels and policy change at the community level. Goals added based on recent evidence that demonstrates the substantial impact of obesity, sodium consumption, and air pollution on cardiovascular health. A major addition has been the listing of current programs which illustrate best practices at national, regional, or local levels © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

12. Table 3. Intervention Goals and Recommended Actions for Public Health Programs Intervention GoalsRecommended Actions Surveillance: Goal: All communities should have access to data that CVD and stroke are leading causes of death and disability for everyone in their community. Determine and make available data on the burden of CVD and stroke morbidity and mortality at the local level (city or county). Identify groups defined by gender, race/ethnicity, socioeconomic status, or geographic location that are at especially high risk of CVD and stroke within each community. Assess the levels of major preventable causes of CVD and stroke in the community including social and environmental factors (e.g., safety, air pollution), lifestyle behaviors (e.g., unhealthy diet, tobacco use, sedentary lifestyle) and risk factors (hypertension, atrial fibrillation, diabetes, elevated blood cholesterol, and obesity). Example: © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

13. Intervention Goals and Current Programs Surveillance: Goal: All communities should have access to data that CVD and stroke are leading causes of death and disability in men and women in their community. American Heart Association (AHA) Heart and Stroke Facts The American Heart Association, in conjunction with the Centers for Disease Control and Prevention, National Institutes of Health and other government agencies, compiles up-to-date statistics on heart disease, stroke and other vascular diseases in the Heart Disease and Stroke Statistical Update. This is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the public and others who seek the best national data available on disease morbidity, mortality and risks; quality of care; medical procedures and operations; and costs associated with the management of these diseases. www.heart.org/statistics CDC State Tobacco Activities Tracking and Evaluation (STATE) System The State Tobacco Activities Tracking and Evaluation (STATE) System is an electronic data warehouse containing up-to-date and historical state-level data on tobacco use prevention and control. http://apps.nccd.cdc.gov/statesystem/Default/Default.aspx Table 4. Intervention Goals and Current Public Health Programs Example: © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

14. The future burden of CVD is projected to increase and have an enormous economic impact Enhanced population-based prevention programs could lead to a large decline in CVD morbidity and mortality. The AHA Community Guide serves to aggregate and integrate the evidence available to date to provide clinical and public health practitioners, community leaders, and policy makers with an overview of the many opportunities to improve their communities cardiovascular health. © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94

15. American Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 Update Citation: Pearson TA, Palaniappan LP, Artinian NT, Carnethon MR, Criqui MH, Daniels SR, Fonarow GC, Fortmann SP, Franklin BA, Galloway JM, Goff DC Jr, Heath GW, Holland Frank AT, Kris-Etherton PM, Labarthe DR, Murabito JM, Sacco RL, Sasson C, Turner MB; on behalf of the American Heart Association Council on Epidemiology and Prevention. American Heart Association guide for improving cardiovascular health at the community level, 2013 update: a scientific statement for public health practitioners, healthcare providers, and health policy makers. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94. Link: http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0b013e31828f8a94 © 2013, American Heart Association, Inc. All rights reserved. Pearson, TA et al. Circulation. 2013: published online before print March 21, 2013, 10.1161/CIR.0b013e31828f8a94