2008 Public Health Action Plan Update: Celebrating Our First Five Years

Action Plan Return to Action Plan Main Page  Sections Overview Milestones/Landmark Events Key Messages Action Plan: Celebrating 5 Years Reflections from the Chair of the Forum Commentary from AHA Commentary from ASTHO Commentary from NACDD and CHC Reducing Heart Disease and Stroke in the U.S. Burden and Disparities Today Making Connections Mission Statements/Strategies Review of  Components and Recommendations Action Framework Implementation Group's Priorities for 2008/2009 Appendix A Appendix B

Burden and Disparities Today: Update from 2003

Section 1 of A Public Health Action Plan to Prevent Heart Disease and Stroke (Action Plan)¹ is “Heart Disease and Stroke Prevention: Time for Action .” This section (“Time for Action”) presents the case for developing an action plan. It includes selected measures of the burden and disparities of heart disease and stroke in the United States.

For this report, the tables in the original “Time for Action” are updated if new data are available (Tables1–4). The intent is to portray the picture of burden and disparities as though the Action Plan were being written today. Additional information is provided by the Healthy People 2010 Midcourse Review² published in December 2006 and by the American Heart Association 2010 Impact Goal Progress Report of June 2007.³ The Midcourse Review reports on progress in heart disease and stroke prevention (Focus Area 12 in Healthy People 2010) with respect to 10 of 16 objectives. The American Heart Association (AHA) report addresses progress on eight indicators for the Association’s goal. Progress has also been made in understanding the global dimensions of cardiovascular diseases in terms of the burden attributable to common risk factors and the cost-effectiveness of interventions.^4,5

These observations and other developments since 2003 demonstrate important progress in some areas. But the urgency of taking effective action is even greater today than a half-decade ago.

The Current Burden

Table 1 compares data for selected available indicators of the cardiovascular disease (CVD) burden in the United States in 2008 with data available in 2003. Indicators shown are mainly those for which comparable data were available. Sources of the data are surveillance systems and studies by the Centers for Disease Control and Prevention (CDC), the National Heart, Lung, and Blood Institute, and others compiled by the American Heart Association.⁶

A comparison of the data related to these indicators for 2005 with those for 2000 reveals two broad patterns of change: for indicators of mortality, every change is favorable; for indicators of morbidity (i.e., number of cases of cardiovascular diseases and of persons with risk factors), the changes are unfavorable with only one exception: reduced prevalence of smoking among people aged 18 years or older. Greater numbers of Americans were living with coronary heart disease, heart failure, stroke, high blood cholesterol, high blood pressure, obesity, and diabetes in 2005 than in 2000: the public health burden of these conditions has increased.

Two points of clarification are important in considering an increase in prevalence. First, any of several factors could explain the increase—greater incidence of new cases, more frequent detection of cases, or increased survival of people with risk factors or disease after the condition is recognized. The latter two factors would reflect improvements in detection or in treatment and control of risk factors or complications. However, regardless of the explanation, greater prevalence indicates an increased public health burden, with attendant costs, that calls attention to the need for earlier intervention to prevent the condition in the first place.

Second, a change in prevalence may be due simply to a change in definition. For example, the marked increase in prevalence of high blood pressure is due in part—but not wholly—to an expanded definition of people with high blood pressure that includes people who were told they had high blood pressure on two or more occasions by a health professional regardless of their current blood pressure level or use of antihypertensive medications. Thus the prevalence value for 2005 cannot be compared directly with that for 2000.

For 2008, estimated direct costs of $296.4 billion and indirect costs of $152.1 billion are projected for all forms of CVD. The total cost ($448.5 billion) is nearly $100 billion greater than the costs only 5 years earlier ($90 billion of the increase is due to the costs of care, and $10 billion is due to lost productivity because of death or disability among people of working age). Some portion of these increases is due to improved methods of estimating, which suggests underestimation in earlier years.⁶

Additional CDC vital statistics data not in Table 1 show further the favorable changes in mortality: ⁶ trends in age-adjusted rates and numbers of deaths from CVD from 1990 to 2000 indicated a 17.0% decrease in the death rate, although the number of deaths increased by 2.5%. Corresponding data for a more recent interval, 1994–2004, indicated a 24.7% decrease in the death rate and an accompanying 8% decrease in number of deaths. For stroke, the corresponding changes during 1990–2000 were similar: a 12.3% decline in the death rate and a 9.9% increase in number of deaths; during 1994–2004 the death rate declined more sharply, by 24.2%, and the number of deaths decreased by 6.8%. These data indicate that age-standardized mortality rates do not necessarily indicate disease burden, which is better measured by actual numbers of deaths.

Taken together, these data for the United States population as a whole mean that declining mortality is accompanied by increasing morbidity due to CVD and sharply increasing costs.

Table 1. Selected Indicators of the Cardiovascular Disease (CVD) Burden, United States,
2005 and 2000

Source: Based on data compiled from the Centers for Disease Control and Prevention, the National Institutes of Health, and other sources and reported by Rosamond et al., Heart Disease and Stroke Statistics Update—2008 (Reference 6).

Disparities by Race or Ethnicity

Table 2 contains the 2004 death rates for heart disease and Table 3, the rates for stroke. They show disparities in heart disease and stroke deaths by race or ethnicity and by sex for 2004,⁷ the most recent year for which completed mortality data are available. Data are shown for men and women in each of five racial or ethnic groups, age-adjusted to the standard population of the United States in 2000.⁷ The relative rates among population subgroups continue to demonstrate marked disparities.

In 2004, blacks had the highest reported rates of both heart disease and stroke deaths for women and men. Relative to non-Hispanic whites, the excess of heart disease deaths among black women was 35% and among black men was 28%; the excess of stroke deaths was 37% for women and 55% for men. The greatest contrast in rates of heart disease deaths among women was 236.5 to 96.1 per 100,000 for blacks versus Asians and Pacific Islanders (a ratio of 2.5:1); for men it was 342.1 to 146.5 per 100,000 for the same groups (a ratio of 2.3:1). The corresponding ratio for stroke for women was 65.5 to 35.1 per 100,000 for blacks versus American Indians or Alaska Natives (a ratio of 1.9:1); for men it was 74.9 to 35.0 per 100,000 for the same groups (a ratio of 2.1). Similar findings were described in the original publication of the Action Plan.

Table 4 has further evidence regarding disparities in years of life lost, risk factors, health care coverage, and poverty. In comparison with the original data provided in “Time for Action,” the effect of death from heart disease, stroke, or diabetes on years of potential life lost appears to have diminished for all groups. Risk factor improvement is limited to reduced prevalence of high cholesterol (≥240 mg/dL), which decreased slightly for men and more sharply for women in each of the three groups for whom data were available. Prevalence of hypertension and obesity increased, especially among women, as did the proportion of most groups in poverty; tobacco use changed little. Lack of health care coverage improved only slightly. Regarding disparities, it is striking first that health data were not reported on any indicator for Native Hawaiians or Pacific Islanders; and risk factor data, except for tobacco use, were unavailable for American Indians, Alaska Natives, or Asians. The lack of data for these groups is one indication of the inadequacy of current health data systems. Estimates from the National Health and Nutrition Examination Survey (NHANES), the source of the risk factor data, were not reliable for these groups because of small sample sizes.

Potential years of life lost remained exceptionally high for African Americans relative to all other groups, for all three causes of death. For heart disease and stroke, these findings are consistent with those in Tables 2 and 3. Tobacco use was notably high for American Indians and Alaska Natives relative to all other groups. Hypertension was highest for African Americans, especially for African American women. Prevalence of high cholesterol differed little among the groups, and the same was true, among men, for obesity. But for African American women, the prevalence of obesity was exceptionally high.

These patterns were similar, although in some respects more pronounced, in the recent data than in the previously published data.¹ Lack of health care coverage changed little during this period, remaining especially frequent among American Indians, Alaska Natives, and Hispanics. Poverty was most frequent for these groups and also for African Americans.

Table 2.  Age-Adjusted Death Rates (per 100,000) for Heart Disease, by Sex and Race or Ethnicity, United States, 2004

Note: Death rates are age-adjusted to the 2000 U.S. standard population.
Source: CDC, NCHS, Health, United States, 2006 (Table 36). (Reference 7)

Table 3.  Age-Adjusted Death Rates (per 100,000) for Stroke, by Sex and Race or Ethnicity,
United States, 2004

Table 4.  Update on Disparities in Selected Health Indicators, by Race or Ethnicity,
United States

Table 4. Notes, Footnotes, and Sources

Notes

• Prevalences of hypertension, total cholesterol, and body mass index (BMI) are age-standardized to the U.S. 2000 standard population.
• N/A indicates data are not available or they do not meet the criteria for statistical reliability, data quality, or confidentiality.
• NSDUH: National Survey on Drug Use and Health
• NHANES: National Health and Nutrition Examination Survey
• NHIS: National Health Interview Survey

Footnotes

1. The NHANES provides reliable estimates for the Mexican American subgroup of Hispanics, but not all Hispanics. Therefore, data are shown for Mexican Americans rather than all Hispanics.
2. Years of potential life lost (YPLL) rates per 100,000 are age standardized to the 2000 U.S standard population.
3. Includes data for Native Hawaiians or other Pacific Islanders.
4. Includes all heart disease deaths coded according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (Geneva, Switzerland: World Health Organization).
5. Includes all cerebrovascular accident deaths (stroke) coded according to the ICD-10.
6. Includes all diabetes deaths coded according to the ICD-10.
7. Defined as having blood pressure >140/90 mm Hg or reporting current antihypertensive therapy.
8. Excludes pregnant women.
9. Non-Hispanic black racial/ethnic categories used in NHIS data.
10. Defined as living in a household with income below the poverty level within the previous 12 months.

Sources

• Years of potential life lost: Centers for Disease Control and Prevention (CDC), (Health, United States, 2007.
• Tobacco use: Substance Abuse and Mental Health Services Administration. NSDUH http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch4)
• Hypertension, total cholesterol, and body mass index: CDC, NHANES
• No health insurance: CDC, NHIS
• Poverty: U.S. Census Bureau. 2006 American Community Survey and Census 2000 (http://factfinder.census.gov/)

Healthy People 2010: Midcourse Review

Focus Area 12 in Healthy People 2010 addresses heart disease and stroke with a goal that has several components: 1) prevention of risk factors; 2) detection and treatment of risk factors; 3) early identification and treatment of heart attacks and strokes; and 4) prevention of recurrent cardiovascular events.2 Within this area, 16 objectives are specified. Nine other focus areas together have 48 additional objectives relevant to heart disease and stroke; all are cross-tabulated in accordance with the four goals in Appendix B of the Action Plan.

The Midcourse Review is a report of progress toward each of the Healthy People 2010 objectives for which baseline and interim data are available. The report on heart disease and stroke addresses 10 of the 16 objectives specific to these conditions. Staff of the Centers for Disease Control and Prevention and the National Institutes of Health, co-lead U.S. public health agencies for heart disease and stroke, collaborated on this report, which is summarized in the Figure. For each objective and subobjective, a “progress quotient” is calculated. This quotient is the observed proportion of change from baseline toward the target value of an objective and is calculated as follows:

For example, prevalence of high total cholesterol values (objective 12−14) was to be reduced from 21% at baseline to 17% by 2010, an absolute difference of 4%. For this objective, the baseline value was from NHANES of 1988–1994 and the most recent value was from NHANES survey of 1999–2002. The observed difference of 4% is 100% of the targeted change, and at midcourse the target had been met, as shown in the Figure.

Figure: Progress Quotient Chart for Focus Healthy People 2010 Area 12: Heart Disease and Stroke

Notes: Tracking data for objectives 12-2, 12-3a and b, 12-4, 12-5, 12-8, and 12-16 are unavailable.
Years in parentheses are the baseline data year and the most recent data year used to compute the percentage of the Healthy People 2010 target achieved.

For eight other objectives, movement toward the targeted changes ranged from 9% to 64%. Death rates for coronary heart disease and stroke and for taking action to help control high blood pressure were more than half way to their targets at midcourse. Mean total blood cholesterol levels and blood cholesterol checked within the previous 5 years were nearly half-way to the targets. Little or no change was found for congestive heart failure hospitalization or controlled high blood pressure . Overall, good progress has been made in several respects.

The contrary finding for prevalence of high blood pressure is cause for serious concern. The baseline level was 26% and the target is 14%. On the basis of the same NHANES sources as cholesterol levels, prevalence of high blood pressure increased by 33% of the target change as of 1999–2002, a change in prevalence from 26% to approximately 30% among adults aged 20 years or older. This change, coupled with the striking increase in prevalence of diabetes and obesity, adds to the total cardiovascular disease burden and threatens to slow progress toward the goals for heart disease and stroke mortality through the remainder of the decade.

Adding to concern about the nation’s course with respect to high blood pressure is the report of increasing blood pressure among children and adolescents from 1988–1994 to 1999–2000.⁸ During this period, the national population mean levels of systolic and diastolic blood pressure increased for each of two age groups, 8–12 and 13–17 years. Increases were greatest for non-Hispanic blacks and Mexican Americans and reached +4.8 mm/Hg overall for those aged 8–12 years. These increases were only partially accounted for by the concurrent increase in body mass index.

Progress Toward the American Heart Association's Impact Goal

The American Heart Association’s impact goal for 2010, as approved in February 2004, is as follows: ³

By 2010, to reduce coronary heart disease, stroke, and risk by 25% by —

• Reducing the death rate from coronary heart disease and stroke by 25%.
• Reducing the prevalence of smoking, high blood cholesterol, and physical inactivity by 25%.
• Reducing the rate of uncontrolled high blood pressure by 25%.
• Eliminating the growth of obesity and diabetes.

As of June 2007, the AHA indicators were reported as follows:

Congruent with other findings, AHA saw progress in several key indicators. In January 2008, AHA reported on CDC’s new release of 2005 mortality data showing decreases of 25.8% in coronary heart disease mortality and 24.4% in stroke mortality.⁶ Favorable changes in high cholesterol prevalence, reductions in tobacco use, and increases in high blood pressure control were also striking. But rates of physical inactivity and obesity continued to lag or worsen; no new data were reported for diabetes prevalence.

A Global Perspective

The global dimensions of epidemic heart disease and stroke are acknowledged more widely and addressed more forcefully today than when A Public Health Action Plan to Prevent Heart Disease and Stroke was first published in 2003. Global Strategy on Diet, Physical Activity and Health,⁹ published by the World Health Organization (WHO) in 2004, calls attention to the urgent need for widespread action to address these fundamental causes of cardiovascular and other chronic or noncommunicable diseases.

According to WHO, 30% of deaths worldwide are due to heart disease or stroke.⁴ Global health experts continue to raise the alarm that chronic diseases are increasing worldwide, particularly in low- and middle-income countries. Beyond the private burden borne by victims and their families, these diseases are a serious threat to the economic well-being of the countries in which the affected people live because many who suffer disease and death are of working age.

A Race Against Time,¹⁰ which also appeared in 2004, demonstrates the potentially crippling effect of cardiovascular disease on developing countries unless action is taken now to protect those who comprise the productive labor force — the economic engine — of these countries. The WHO report of 2005 Preventing Chronic Diseases: A Vital Investment⁴ provides an overview of the risk factors and burden of chronic disease (including CVD) worldwide, reviews evidence-based interventions for populations and individuals, and outlines a public health approach to reducing chronic disease. WHO proposes a new global goal to reduce the projected trend of death rates due to chronic disease by 2% each year until 2015.

WHO’s Framework Convention on Tobacco Control,¹¹ published in 2003, became effective 27 February 2005 and, as of January 2008, had 168 signatories and 151 ratifying parties among the nations of the world. This first global treaty on health offers hope of limiting the ravages of the epidemic of tobacco use, including its contribution to the toll of death and disability from cardiovascular diseases.

Global Burden of Disease and Risk Factors,¹² published in 2006, greatly extends the resources for policy development by estimating the attributable burden of disease related to major risk factors on a regional and subregional basis worldwide. And Disease Control Priorities in Developing Countries (2nd Edition),⁵ a 2006 product of the Disease Control Priorities Project of the World Bank, outlines in detail the outcome of cost-effectiveness assessments of the most promising population-level interventions to prevent cardiovascular diseases and other major public health burdens throughout the developing world.

Conclusions

The summary of “Time for Action” in 2003 concluded as follows:

An unprecedented opportunity exists today to develop and implement an effective public health strategy to prevent heart disease and stroke. Three major factors have contributed to this opportunity:

• More cumulative knowledge and experience in CVD prevention exists today than ever before.
• Major national partnerships have been established to support heart disease and stroke prevention.
• Health professionals increasingly recognize the continuing CVD epidemic, unfavorable recent trends, and forecasts of a mounting burden of heart disease and stroke, nationally and worldwide. This recognition has increased their awareness of the need for immediate action.

Despite this opportunity, the public health investment in preventing heart disease and stroke remains far below what is needed for fully effective intervention. Serious shortcomings also exist in the delivery of established treatments for these conditions in clinical practice. These facts demonstrate that the vast body of current knowledge and experience in CVD prevention has yet to be adequately applied to realize the full potential benefit to the public’s health . The most critical need today is for public health action that is guided by the knowledge and experience already at hand.

These elements of the rationale for public health action are strongly reinforced by current data and by the interim developments that include, prominently, establishment of the National Forum for Heart Disease and Stroke Prevention as the principal vehicle for implementing the Action Plan.

Three strategic imperatives remain critical to successful implementation:

We must —

• Strike a new balance in our investment in health by putting prevention first.
• Transform our public health agencies into effective instruments for leading policy and environmental change and for supporting the entire range of public health approaches to heart disease and stroke prevention.
• Prevent the causes themselves of heart disease and stroke (i.e., not wait to treat the causes or the consequences of disease when their prevention is possible).

A Public Health Action Plan to Prevent Heart Disease and Stroke continues to chart a course whose pursuit during the remainder of this decade and through the next is vital to the present and future health of this nation and the world.

References

1. U.S. Department of Health and Human Services. A public health action plan to prevent heart disease and stroke. Atlanta, GA: Centers for Disease Control and Prevention; 2003.
2. U.S. Department of Health and Human Services. Healthy people 2010: midcourse review. Washington, DC: Government Printing Office; 2006. Available at: http://www.healthypeople.gov/data/midcourse/html/focusareas/FA12ProgressHP.htm
3. American Heart Association. American Heart Association impact goal progress. Dallas, TX: AHA; 2007. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3050838*
4. World Health Organization (WHO). Preventing chronic diseases: a vital investment. Geneva, Switzerland: WHO; 2005. Available at: http://www.who.int/chp/chronic_disease_report/en/index.html.*
5. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., Editors. Disease control priorities in developing countries, 2nd edition. Washington, DC: International Bank for Reconstruction and Development/The World Bank; 2006.
6. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Heart disease and stroke statistics: 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;115:e69-e171.
7. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics. Health, United States. Atlanta, GA: CDC; 2006
8. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA 2004;291:2107-13.
9. World Health Organization (WHO). Global strategy on diet, physical activity and health. Geneva, Switzerland: WHO; 2004.
10. Leeder S, Raymond S, Greenberg H. A race against time: the challenge of cardiovascular disease in developing countries. New York, NY: Columbia University; 2004.
11. World Health Organization (WHO). WHO framework convention on tobacco control. Geneva, Switzerland: WHO; 2003.
12. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, editors. Global burden of disease and risk factors. Washington, DC: The International Bank for Reconstruction and Development/The World Bank; 2006.

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Page last reviewed: August 8, 2008
Page last modified: August 8, 2008
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion