3
The Role of the Division for Heart Desease and Stroke Prevention in the Prevention and Control of Hypertension

Critical to any organization is its capacity to achieve its mission and goals; thus, the resources available and the authority it has to address its charge are fundamental to its ability to act. This chapter provides a brief overview of the Centers for Disease Control and Prevention’s (CDC’s) Division for Heart Disease and Stroke Prevention, its resources, the legislative history of relevant programs, and an overview of activities directed at preventing and reducing hypertension in the United States.

The Cardiovascular Health Studies Branch, established in 1989 within the Division of Adult and Community Health in the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), was the focal point for limited cardiovascular prevention and control activities at the CDC. Over the ensuing 17 years, the CDC’s activities in this area grew in part as a result of the increasing concern about the growing burden of cardiovascular disease and congressional action that provided the CDC with funds to improve the cardiovascular health of Americans. Today, cardiovascular disease prevention and control activities are under the purview of the Division for Heart Disease and Stroke Prevention (DHDSP). The charge of the division is to lead the nation’s cardiovascular health initiatives and to reduce the burden of disparities associated with heart disease and stroke. The DHDSP’s core functions include programs, surveillance, research, evaluation, and partnerships. Its activities are distributed among four primary programs: (1) the National Heart Disease and Stroke Prevention Program, (2) WISEWOMAN, (3) the Paul Coverdell National Acute Stroke Registry, and (4) the State Cardiovascular Health Examination Survey. Although not listed as a specific program, Congress directed the



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3 The Role of the Division for Heart Disease  and Stroke Prevention in the Prevention  and Control of Hypertension C ritical to any organization is its capacity to achieve its mission and goals; thus, the resources available and the authority it has to address its charge are fundamental to its ability to act. This chapter provides a brief overview of the Centers for Disease Control and Prevention’s (CDC’s) Division for Heart Disease and Stroke Prevention, its resources, the legisla- tive history of relevant programs, and an overview of activities directed at preventing and reducing hypertension in the United States. The Cardiovascular Health Studies Branch, established in 1989 within the Division of Adult and Community Health in the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), was the focal point for limited cardiovascular prevention and control activities at the CDC. Over the ensuing 17 years, the CDC’s activities in this area grew in part as a result of the increasing concern about the growing burden of cardiovascular disease and congressional action that provided the CDC with funds to improve the cardiovascular health of Americans. Today, car- diovascular disease prevention and control activities are under the purview of the Division for Heart Disease and Stroke Prevention (DHDSP). The charge of the division is to lead the nation’s cardiovascular health initia- tives and to reduce the burden of disparities associated with heart disease and stroke. The DHDSP’s core functions include programs, surveillance, research, evaluation, and partnerships. Its activities are distributed among four primary programs: (1) the National Heart Disease and Stroke Preven- tion Program, (2) WISEWOMAN, (3) the Paul Coverdell National Acute Stroke Registry, and (4) the State Cardiovascular Health Examination Survey. Although not listed as a specific program, Congress directed the 

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION TAbLE 3-1 DHDSP Administrative and Program Budgets (FY 2008) Percentage of Total Core Function Administrative Budget Administrative Budget Programs $49,259,915 74% Surveillance $5,672,580 8% Research $3,915,689 6% Evaluation $4,155,207 6% Partnerships $3,862,683 6% Percentage of Total Programs Program Budget Program Budget State Heart Disease and Stroke $27,770,783 56% Prevention Program WISEWOMAN $15,499,336 32% Paul Coverdell National Acute $4,400,000 9% Stroke Registry State Cardiovascular Health $399,751 1% Examination Survey Other $1,190,045 2% DHDSP to address sodium reduction in the American diet, but it did not appropriate funding for this activity. PROGRAMMATIC FuNDING In 1998, the DHDSP budget was $10.7 million. Its budget increased gradually to about $44 million in 2005 and remained relatively constant until 2008 when the budget increased to about $50 million. The DHDSP budget appropriated for fiscal year (FY) 2009 was approximately $54 mil- lion. The division’s administrative budget is divided among five core func- tions, which are listed in Table 3-1 with their respective budgets; program expenditures, which represent almost 75 percent of the DHDSP budget, are also itemized. The budget distribution shown is for FY 2008 because the final resource allocation for 2009 had not been determined at the time of this writing. NATIONAL HEART DISEASE AND STROKE PREVENTION PROGRAM Established in 1998, the State Heart Disease and Stroke Prevention Pro- gram is the division’s largest program. The program funds or provides tools, guidance, and other assistance to all 50 states; thus, it is now referred to as a national program. While there is no specific language authorizing the pro-

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 THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION gram, funds are appropriated each year in the Labor, Health and Human Service appropriations bill (or in continuing appropriations resolutions). The program was initially established in response to congressional concern that nearly 1 million Americans were dying each year from cardiovascular disease and the knowledge that the major risk factors for cardiovascular disease were modifiable and often preventable. Of further concern was that states did not receive specific federal funds, and many states had limited resources to dedicate to the prevention of cardiovascular disease. The con- gressional vision was that of an integrated, comprehensive, and nationwide program to provide assistance to states; support research, surveillance, and laboratory capacity; and reduce risk factors for cardiovascular disease by promoting healthy behaviors. The program was to give priority to those states with the highest age-adjusted death rates due to cardiovascular dis- ease. To carry out this responsibility, Congress appropriated $8.1 million to the CDC for the program. Currently the program provides funds to state health departments in 41 states and the District of Columbia. The six primary program priorities are to (1) control high blood pressure, (2) control high cholesterol, (3) improve emergency response, (4) improve the quality of care, (5) increase awareness of the signs and symptoms of heart attack and stroke and of the need to call 9-1-1, and (6) eliminate health disparities related to heart disease and stroke. Within these broad priorities, states are encouraged to focus on policy and system change, effect population-based change, ensure cultural competency, engage partners, and work within the health care, worksite, and community settings. Under the program, states can be funded at the level of Capacity Build- ing or Basic Implementation. Twenty-eight states receive $300,000 annually at the Capacity Building level. Their priorities include increasing collabora- tion between public and private partners, defining the existing burden of heart disease and stroke in the state, assessing ongoing population-based interventions, and developing a comprehensive state plan. There is also an emphasis on identifying culturally appropriate approaches to raise aware- ness and promote healthy behaviors. Fourteen states receive Basic Imple- mentation funding in the amount of $1 million dollars annually. These states implement and evaluate policies, offer environmental and educational interventions in various settings, and facilitate provider education and training. In an effort to assist in the outcome evaluation of heart disease and stroke prevention activities within states, the DHDSP developed policy and systems outcome indicators for controlling high blood pressure. State HDSP programs may use these indicators to support the development of an evaluation plan. The Logic Model for Strategies and Interventions to Reduce High Blood Pressure (Figure 3-1) provides parameters for effec-

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION Overall Logic Model for Strategies and Interventions to Reduce H igh Blood Pressure [HBP] Input Activities Outputs Short- term Outcomes Intermediate Outcomes Long- term Outcomes Health care system changes: • Policies/protocols/tools 1 • Adherence Risk factor reduction through • Efficiency lifestyle and therapeutic Reduced mortality and morbidity intervention 6 due to heart disease and stroke 9 Provider changes: • Awareness 2 • Adherence to guidelines Individual changes: Reduced levels of disparities in • Awareness heart disease and stroke 10 • Motivation Reduced levels of BP • Adherence to treatment 5 7 • Satisfaction Reduced costs associated with heart disease and stroke: Worksite changes: 3 •Policies/protocols/tools • Health care 11 •Environmental changes • Employer • Societal Increased control of BP levels among individuals with HBP 8 Community changes: 4 • Environmental changes • Policy/legislative changes Contextual Factors • Socioeconomic and demographic characteristics of the target population • Participating organizations’ policies and practices • Health care industry practice trends and policies 1 • Partnerships among patients, providers, health care organizations, and worksites FIGuRE 3-1 Overall logic model for strategies and interventions to reduce high blood pressure (HBP). SOURCE: Ladd et al., 2010. tive intervention strategies. Each high blood pressure control outcome Figure 3-1 grayscale indicator identified in the DHDSP’s draft document can be nested within a component outlined in the logic model. The model includes a spectrum of intervention approaches, including health care system changes, provider changes, individual changes, worksite changes, and community changes, that can effectively reduce the burden of risk factors and disease. State programs decide where along the logic model they will focus their program efforts and resources. The committee did not attempt to conduct a systematic review of state programs; however, based on a highlight of state activities provided by the DHDSP, many states tend to focus on sec- ondary prevention activities. Such activities include improving the quality of care for individuals through clinical performance measurement (North Carolina, Utah), education and training of health care providers (Georgia, South Carolina, Virginia), and worksite wellness programs (Kansas, Maine, Missouri). Some primary and secondary prevention activities are addressed through programs that increase awareness and educate about risk factors and lifestyle changes (Oregon).

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9 THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION WISEWOMAN (WELL-INTEGRATED SCREENING AND EVALuATION FOR WOMEN ACROSS THE NATION) Congress, through the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354) provided the authority and funding for the CDC’s National Breast and Cervical Cancer Early Detection Program and the WISEWOMAN program. The WISEWOMAN provision allowed for: (a) Demonstration projects. In the case of States receiving grants under section 1501 [42 U.S.C. § 300k], the Secretary, acting through the Direc- tor of the Centers for Disease Control and Prevention, may make grants to not more than 3 such States to carry out demonstration projects for the purpose of– (1) providing preventive health services in addition to the services authorized in such section, including screenings regarding blood pressure and cholesterol, and including health education; (2) providing appropriate referrals for medical treatment of women receiving services pursuant to paragraph (1) and ensuring, to the extent practicable, the provision of appropriate follow-up services; and (3) evaluating activities conducted under paragraphs (1) and (2) through appropriate surveillance or program-monitoring activities. The legislation specifically required that grants for the program be provided only through entities that screen women for breast or cervical cancer through the National Breast and Cervical Cancer Early Detection Program. As the name of the program suggests, the legislation integrates and leverages the services and efforts of a cancer screening and evaluation program with a primary prevention program to reduce cardiovascular risk in women. The program was initially funded in 1996 at the amount of $3 mil- lion and was situated in the Division of Nutrition, Physical Activity and Obesity; in 1998, the program was transferred to DHDSP. By FY 2009, the budget had increased to $19.5 million, with an average of $600,000 dedicated to each of the 21 programs operating throughout the United States. Of WISEWOMAN funding, 80 percent is directed to programs, and within that amount, 60 percent is allocated to primary prevention through screening for hypertension, cholesterol, and (more recently) diabetes. The remaining 40 percent of funding is directed to administration, data collec- tion, and evaluation. The WISEWOMAN program provides screening and lifestyle interven- tions to low-income, uninsured, or underinsured woman between the ages of 40 and 64. WISEWOMAN has reached more than 84,000 women in need since the year 2000, providing approximately 149,000 health screen- ings and 210,500 lifestyle interventions through its 21 state and tribal

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0 APPROACH TO PREVENT AND CONTROL HYPERTENSION programs. More than 7,674 new cases of hypertension have been identi- fied through WISEWOMAN screenings, as well as 7,928 cases of high cholesterol and 1,140 cases of diabetes. Women who participated in WISE- WOMAN are reportedly more likely to return for regular health screenings. A recent review of 14 WISEWOMAN programs found that the average reduction in systolic blood pressure after 1 year was 2.7 mm Hg, although it ranged from an increase of 5.0 mm Hg to a decrease of 8.0 mm Hg in the programs studied (Farris et al., 2007). The Nebraska WISEWOMAN program was highlighted by Secretary of Health and Human Services Dr. Kathleen Sebelius in a recent report describing health care success stories. She observed that 19,000 women have been reached in Nebraska alone, helping to reduce their risk of heart attack and stroke. Dr. Sebelius encouraged building on the success of the WISEWOMAN program, which she said has provided evidence of the importance and success of prevention programs (Montz and Seshamani, 2009). THE PAuL COVERDELL NATIONAL ACuTE STROKE REGISTRy The CDC’s effort to create state-based stroke registries was initiated in 2001 as a result of congressional language in the CDC Heart Disease and Stroke appropriations budget line. The program is also included in FY 2002-2005 appropriations; since then, no specific congressional language regarding the program has been included in appropriations, but the CDC has maintained funding for the program through the appropriations for Heart Disease and Stroke. Through the initial legislative language, Con- gress awarded the CDC $4.5 million to track and improve the delivery of care to patients with acute stroke. As a first step, the CDC was to consult with stroke organizations and others to develop specific data elements for a stroke registry and to design and pilot registry prototypes. The focus of the registry data collection effort was to measure the quality of care deliv- ered to stroke patients from emergency response to hospital care. Between 2001 and 2002, eight states participated in piloting prototype projects (California, Georgia, Illinois, Massachusetts, Michigan, North Carolina, Ohio, and Oregon). Results from these pilot projects revealed disparities between generally recommended standards for treating stroke patients and actual hospital practices. In 2004, four of the pilot states were funded to establish statewide registries (Georgia, Illinois, Massachusetts, and North Carolina) to collect and analyze data and implement quality improvement interventions at the hospital level. In 2007, funding was extended to six state health departments (Georgia, Massachusetts, Michigan, Minnesota, North Carolina, and Ohio) for a new 5-year period. In that same year, the CDC, along with The Joint Commission’s Primary Stroke Center Certifi-

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1 THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION cation Program and the American Stroke Association’s (a division of the American Heart Association) Get with the Guidelines Stroke Program, formed an agreement to jointly release a set of standardized stroke perfor- mance measures. These guidelines are intended to foster collaboration and encourage hospital participation. STATE CARDIOVASCuLAR HEALTH EXAMINATION SuRVEy The State Cardiovascular Health Examination Survey was initiated in 2005 in an attempt to advance state capacity in the development of hy- pertension and cholesterol control strategies. A Heart Disease and Stroke Prevention Program funding opportunity announcement provided the initial funding, but the program now has its own funding opportunity announce- ment. States must receive funding from the DHDSP as a prerequisite to receiving state cardiovascular health examination funds. Three state health departments (Arkansas, Kansas, and Washington) were the initial awardees; Oklahoma was added in 2007. State awardees design a survey to collect data on blood pressure, cholesterol, and other relevant cardiovascular health information, including risk factors and health behaviors. The goal of the program is to provide data with which to monitor progress toward the Healthy People 2010 objectives related to control of high blood pressure and high cholesterol. ACTIVITIES TO REDuCE SODIuM INTAKE Congress, through the Omnibus Appropriations Act (Public Law 111-8) in the Joint Explanatory Statement: Division F—Labor, Health and Human Services, and Education, and Related Agencies Appropriations, 2009, in- cluded an unfunded mandate for the CDC to engage in activities to reduce sodium. The statement specifically states: A diet high in sodium is a major cause of heart disease and stroke. CDC is encouraged to work with major food manufacturers and chain restaurants to reduce sodium levels in their products. The agency is directed to submit to the Committees on Appropriations and the House of Representatives and the Senate an evaluation of its sodium-reduction activities by no later than 15 months after the enactment of this Act, and annually thereafter. In January 2009, the DHDSP and the National Heart, Lung, and Blood Institute (NHLBI) commissioned the Food and Nutrition Board of the In- stitute of Medicine (IOM) to form an ad hoc Committee on Strategies to Reduce Sodium Intake. The committee is cosponsored by the Health and Human Services’ Food and Drug Administration and the Office of Disease Prevention and Health Promotion (Office of Public Health and Science,

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2 APPROACH TO PREVENT AND CONTROL HYPERTENSION Office of the Secretary). The committee is tasked with identifying means to reduce dietary sodium intake to levels recommended by the Dietary Guidelines for Americans (HHS and USDA, 2005). A range of approaches will be reviewed, including regulatory and legislative actions, new product development, and food reformulation, as well as public health and educa- tional interventions. Opportunities to foster collaborations among industry, government, and the health care enterprise will be considered. The antici- pated publication date of the consensus report is early 2010. OTHER PROGRAMMATIC ACTIVITIES Healthy People The DHDSP, along with the National Institutes of Health (NIH), is responsible for monitoring progress toward reaching Healthy People goals related to cardiovascular health. Healthy People is a national prevention agenda that was first articulated in 1979 by the Department of Health, Education, and Welfare through Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (DHEW, 1979). The IOM and the 1978 Departmental Task Force on Disease Prevention and Health Promotion contributed to its preparation. The report’s central theme emphasized the role of individuals, as well as public and private sector decision makers, in promoting healthier lifestyles. Blood pressure screen- ing, along with the elimination of cigarette smoking and dietary changes to reduce intake of excess calories, fat, salt, and sugar, were identified as health-enhancing measures “within the practical grasp of most Americans.” The reduction of heart attacks and strokes was a subgoal identified in the report’s section dedicated to healthy adults. Increased efforts in “preven- tive measures such as high blood pressure detection and control, reduction of smoking, prudent diet, increased exercise and fitness, and better stress management” were suggested strategies in working toward this subgoal. Promoting Health/Preventing Disease: Objectives for the Nation (HHS, 1980) was released as a companion to this report in 1980; it identified 226 specific, measurable, health objectives and strategies for achieving them. Healthy People 2000 (HHS, 1991), released in 1990, set forth 22 prior- ity areas, including one on heart disease and stroke (Priority Area 15). At that time, the NHLBI was designated as the lead agency assigned to this area. The objectives identified in this area included the reduction of coro- nary heart disease and stroke deaths and also addressed cholesterol, smok- ing, dietary fat, physical activity, and overweight. The objectives relating to hypertension included efforts to increase control of high blood pressure, increase therapeutic actions by those with high blood pressure, and increase blood pressure screening.

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 THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION Released in 2000, the Healthy People 2010 (HHS, 2000a,b) report builds on Healthy People 2000. It consolidated 16 objectives for heart disease and stroke prevention into one section (Focus Area 12). The CDC joined with the NHLBI to co-lead and share accountability for progress toward achieving these objectives. The following objectives relate specifi- cally to hypertension: • Reduce the proportion of adults with high blood pressure. • ncrease the proportion of adults with high blood pressure whose I blood pressure is under control. • ncrease the proportion of adults with high blood pressure who I are taking action (for example, losing weight, increasing physical activity, and reducing sodium intake) to help control their blood pressure. • ncrease the proportion of adults who have had their blood pressure I measured within the preceding two years and can state whether their blood pressure was normal or high. • ncrease the proportion of persons aged 2 years and older who I consume 2,400 mg or less of sodium daily. Other partners engaged in working with the DHDSP and NHLBI to achieve these goals included other CDC units, other federal agencies, and the American Heart Association. The Memorandum of Understanding signed by these partners in 2001 created the Healthy People 2010 Partner- ship for Heart Disease and Stroke Prevention, which in 2003 became the National Forum for Heart Disease and Stroke Prevention and includes a much broader array of participants. The Partnership/Forum began charting a public health action plan to work toward achieving the Healthy People goals. The action plan follows later in this section. The Healthy People 2010 Midcourse Review (HHS, 2006) assessed prog- ress toward the 10 (out of 16) objectives related to heart disease and stroke for which data were available. The results are summarized in Figure 3-2. The problem of hypertension is addressed in the following paragraphs: … 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 [National Health and Nutrition Examination Survey] 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.

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION FIGuRE 3-2 Progress quotient chart for Healthy People 2010 Focus Area 12: Heart Disease and Stroke. SOURCE: HHS, 2006. 3-2 combined from PDF

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 THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION 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. . . . 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. (HHS, 2008, p. 34) Clearly, there is concern that the increasing prevalence of high blood pressure in adults and increasing blood pressure levels in children is moving in the wrong direction from the specified goals. A Public Health Action Plan to Prevent Heart Disease and Stroke The DHDSP, as a co-lead partner in the National Forum for Heart Disease and Stroke Prevention, initiated the development of the Public Health Action Plan to Prevent Heart Disease and Stroke (HHS, 2003). It was responsible for overall planning and execution and for coordinating input from partners, working groups, and expert panels. The resulting Ac- tion Plan, issued in 2003 and updated in 2008, was viewed as a “call to action for tackling one our nation’s foremost challenges, to prevent and control chronic diseases” (HHS, 2003, p. v). The plan provides a vision for the future and a framework of action for public health practitioners and policy makers in the areas of preventing the development of risk factors for heart disease and stroke; detecting and treating risk factors; achieving early identification and treatment of cardiovascular disease and stroke, especially in the acute phases; and preventing the recurrence and complications of heart disease and stroke. The Action Plan is not specific to the prevention and control of hy- pertension; rather, it is written for the most part in the general terms of preventing heart disease and stroke. Two recommendations were considered fundamental to the plan: Effective Communication: • he urgency and promise of preventing heart disease and stroke T and their precursors (i.e., atherosclerosis, high blood pressure, and their risk factors and determinants) must be communicated effec- tively by the public health community through a new long-term strategy of public information and education. This new strategy must engage national, state, and local policy makers and other stakeholders. (Revised in 2008 to include: As a matter of emphasis,

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION special consideration must be paid to those most at risk. Communi- cation strategies should utilize the most current forms of available technology as well at those communication devices that are acces- sible in various communities in the United States and globally.) Strategic Leadership, Partnership, and Organization: • he nations’ public health agencies and their partners (revised in T 2008 to include: and the public) must provide the necessary lead- ership for a comprehensive public health strategy to prevent heart disease and stroke. (HHS, 2008) Among the remaining 22 recommendations, two included direct refer- ence to blood pressure. Advancing Policy: Defining the Issues and Finding the Needed Solutions: • onduct and facilitate research by means of collaboration among C interested parties to identify new policy, environmental, and so- ciocultural priorities for CVH [cardiovascular health] promotion. Once the priorities are identified, determine the best methods for translating, disseminating, and sustaining them. Fund research to identify barriers and effective interventions in order to translate science into practice and thereby improve access to and use of qual- ity health care and improve outcomes for patients with or at risk for CVD [cardiovascular disease]. Conduct economics research, including cost-effectiveness studies and comprehensive economic models that assess the return on investment for CVH promotion as well as primary and secondary CVD prevention. As an example, research to assess community-wide interventions aimed at maintaining and restoring low blood cholesterol levels and low blood pressure, which help prevent atherosclerosis and high blood pressure, are suggested. This recommendation was designated a 2008-2009 priority. • esign, plan, implement, and evaluate a comprehensive interven- D tion for children and youth in school, family, and community set- tings. This intervention must address dietary imbalances, physical inactivity, tobacco use, and other determinants in order to prevent development of risk factors and progression of atherosclerosis and high blood pressure. A full list of the updated 22 recommendations is included in Appendix C.

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 THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION DIVISION FOR HEART DISEASE AND STROKE PREVENTION STRATEGIC PLAN The DHDSP’s Strategic Plan is modeled on the Healthy People 2010 goals related to heart disease and stroke and the recommendations set forth in A Public Health Action Plan to Prevent Heart Disease and Stroke (HHS, 2003). The division is focused on efforts to (1) prevent risk factors for heart disease and stroke; (2) increase detection and treatment of risk factors; (3) increase detection and treatment of heart disease and stroke; (4) decrease recurrences of heart disease and stroke; and (5) foster a skilled and engaged public health workforce (Appendix D). Several priority areas were identified as areas of emphasis over the course of the next several years. The first priority is the enhancement of collaboration by the CDC with federal, state, and local agencies and with nongovernmental organizations to mo- bilize prevention efforts. The division will also prioritize efforts to identify and address at-risk populations to prevent disparities associated with heart disease and stroke. An internal Disparities Workgroup was formed in 2007 in support of this effort. DHDSP COLLAbORATION WITH OTHER CDC uNITS Many of the DHDSP’s programmatic efforts focus on secondary pre- vention of heart disease and stroke with limited primary prevention activi- ties. Some of the relevant primary prevention activities are the domain of other divisions of the National Coordinating Center for Chronic Disease Prevention and Health Promotion that focus broadly on preventing chronic diseases and their risk factors. These divisions work as separate organi- zational units, each with its own budget and mission related to a specific disease, risk factor(s), or vulnerable population. Some of these units also address adolescents and young adults. According to division staff, the DHDSP maintains an ongoing working relationship with its sister divisions and will collaborate on relevant efforts. Table 3-2 lists FY 2009 funding and program descriptions for CDC units with which the DHDSP collaborates. For example, the DHDSP leads the Cardiovascular Health Collabora- tion, a monthly meeting of NCCDPHP division leadership and representa- tives from other CDC centers to discuss important and timely cardiovascular health-related issues. The DHDSP collaborated with the Office on Smoking and Health (OSH) on an IOM report about the effects of secondhand smoke and acute cardiac events and connected the WISEWOMAN programs with tobacco quit lines. As noted earlier, the DHDSP is also working with the Division of Nutrition, Physical Activity, and Obesity on an IOM consensus study to identify strategies for reducing sodium in the food supply as well as a broader salt initiative and related issues such as menu labeling.

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION TAbLE 3-2 CDC Units or Programs, Funding and Program Description FY 2009 CDC Unit or Funding Program (millions) Program Description Division for $54.1 Heart Disease and Stroke Prevention (DHDSP) Division of $57.6 DASH funds education and health agencies in 22 Adolescent and states and 1 tribal government to help schools School Health implement a coordinated school health approach, (DASH) with an emphasis on promoting physical activity, healthy eating, and a tobacco-free lifestyle. The CDC also funds 50 state education agencies (including the District of Columbia), 1 tribal government, 6 territorial education agencies, and 16 large urban school districts for school-based HIV prevention. Ten large urban school districts receive CDC support for school-based asthma management programs. Division of $44.3 DNPAO funds health departments in 23 states to Nutrition, Physical coordinate statewide efforts with multiple partners Activity, and to address obesity. The program’s focus is on policy Obesity (DNPAO) and environmental change initiatives directed toward increasing physical activity; consumption of fruits and vegetables; breastfeeding initiation, duration, and exclusivity; and decreasing television viewing and consumption of sugar-sweetened beverages and high-energy-dense foods (foods high in calories). Division of Adult and Community Health (DACH) Racial and Ethnic $35.6 REACH supports community coalitions that design, Approaches to implement, evaluate, and disseminate community- Community driven strategies to eliminate health disparities in key Health (REACH) areas. REACH supports the CDC’s strategic goals by addressing health disparities throughout infancy, childhood, adolescence, adulthood, and older adulthood. This program has developed innovative approaches that focus on racial and ethnic groups and is improving people’s health in communities, health care settings, schools, and work sites.

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9 THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION TAbLE 3-2 Continued FY 2009 CDC Unit or Funding Program (millions) Program Description Healthy $22.8 DACH currently provides guidance, technical Communities assistance, and training to 12 Strategic Alliance for Health communities selected to represent a mix of urban, rural, and tribal communities. DACH will also train and support more than 200 ACHIEVE (Action Communities for Health, Innovation, and Environmental Change) communities over the next several years. ACHIEVE selects communities to participate in an Action Institute, which convenes community action teams and trains community leaders making policy, systems, and environmental changes to prevent and control chronic diseases and their risk factors. DACH also supports the YMCA of the Pioneering Healthier Communities initiative. Preventive Health $102.0 The PHHS block grant provides funding for all and Health 50 states, the District of Columbia, 2 tribes, and 8 Services (PHHS) territories to tailor prevention and health promotion Block Grant programs to their particular public health needs. The block grant gives its grantees the flexibility to target funds to prevent and control chronic diseases such as heart disease, diabetes, and arthritis and helps them to respond quickly to outbreaks of food-borne infections and waterborne diseases. Prevention $31.1 The CDC supports 33 centers associated with Research Centers schools of public health or medicine throughout (PRCs) the country. Each center conducts at least one core research project with an underserved population that has a disproportionately large burden of disease and disability. All centers share a common goal of addressing behaviors and environmental factors that contribute to chronic diseases such as cancer, heart disease, and diabetes. Several PRCs also address injury, infectious disease, mental health, oral health, and global health. Office on $106.2 OSH funds programs in all 50 states, the District Smoking and of Columbia, 8 territories or jurisdictions, and 7 Health (OSH) tribal-serving organizations. In addition, the CDC funds national networks to reduce tobacco use among specific populations. The CDC also provides funding to 22 state education agencies and 1 tribal government for coordinated school health programs to help prevent tobacco use. SOURCE: Personal communication, D. Labarthe, Centers for Disease Control and Prevention, May 15, 2009.

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