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24. Cardiovascular Disease
Heart disease and stroke are the first and fourth
leading killers of Americans. Since 1950, death rates
for these two cardiovascular diseases have declined
substantially: 47 percent for heart disease and 69
percent for stroke. As a result, stroke has dropped
from the third to the fourth leading cause of death.t
To maintain these impressive improvements,
however, 42 witnesses called for continued efforts
aimed at reducing the primary risk factors associated
with cardiovascular disease (CVD), high blood pres-
sure (hypertension), high serum cholesterol level
(hypercholesterolemia), and smoking-as well as the
secondary risk factors of sedentary lifestyles and
obesity. Because three of these five risks are treated
in some depth in separate chapters within this docu-
ment (tobacco, Chapter 10; nutrition, Chapter 12; and
physical activity, Chapter 13), the focus here is
primarily on hypertension and high cholesterol.
Although these two risks are associated with
separate genetic and environmental factors, several
common approaches to their control are identified, as
are several common populations that require special
attention. Dietary change is the strategy raised most
often for combating both high blood pressure and
high cholesterol; food labeling also is mentioned
repeatedly as a way to help individuals adopt healthy
diets. Other strategies to prevent both hypertension
and high cholesterol include public and professional
awareness, screening, follow-up, and compliance,
according to witnesses.
Minorities, especially Hispanics and Blacks, are
seen as particularly- vulnerable to CVD. For example,
Michael Crawford of the University of Texas Health
Science Center at San Antonio says that from 1970 to
1980 in San Antonio, among males aged 35 to 44,
non-Hispanic Whites experienced an 8 percent decline
in heart disease mortality, whereas Hispanic males
experienced a 62 percent rise. He states, "across all
age categories we see the same trend; that the Hispa-
nic male is not experiencing this decline to the extent
that the non-Hispanic White is, and in some age
categories, the younger men have increased in this
mortality." Crawford calls for education designed
especially to encourage Hispanic men to alter their
lifestyles. (~743)
Also singled out as needing special attention are
the elderly, the medically or economically disad
vantaged, and males. Although some risk factors for
CVD can be found in young children and teenagers
(#182; #261), disagreement exists on how rigorously
and how early interventions should be started. A
number of testifiers see funding for research and for
surveillance as a problem in need of attention be-
tween now and the year 2000.
HYPERTENSION
Several witnesses noted that when the 1990 Objectives
were written, high blood pressure was defined as
160/95 mm/Ha or higher. Since then, however,
studies have demonstrated the value of treating mild
hypertension, and the definition of high blood pres-
sure has changed to 140~90. The objectives should
reflect that change, according to witnesses. (~591)
To help prevent hypertension, the American Heart
Association (AMA) dietary guidelines call for efforts
to reduce sodium intake.
Sodium intake currently far exceeds the physio-
logical needs of healthy Americans. The body
can function quite normally and indefinitely with
sodium intakes of less than 0.2 gram per day.
Present consumption has been estimated at 4 to
5 grams per day. Cross-cultural studies show a
clear relationship between the incidence of high
blood pressure and the sodium content of the
habitual diet. The AHA believes that the
epidemiologic evidence is compelling and that a
reduction of sodium intake to 1 gram per 1,000
calories, not to exceed 3 grams, Is safe, feasible,
and likely useful in prevention of high blood
pressure in many Americans. This represents 2
grams of sodium per day for the average person
consuming 2,000 calories.2 (~636)
The Salt Institute, however, says that new data
about the relationship between sodium or salt intake
and hypertension also argue for changing the 1990
Objectives on that subject. On the basis of these
studies, researchers concluded that for two-thirds of
the population a general recommendation to reduce
sodium chloride intake would have no benefit and
could be harmful. (~082) "It seems clear that the
question of diet and hypertension is so complicated
Cardiovascular Disease 181
OCR for page 182
and dependent on individual (probably genetic) factors
that a general population dietary guideline is inap-
propriate," according to Richard Hanneman. (~082)
Although only one-third of the population is
thought to be salt sensitive, a reviewer points out that
no one knows who those 80 million Americans are.
Because there is no known benefit from consuming
large amounts of salt, and substantial benefit can be
gained by a large number of people from cutting
down, many believe that a general recommendation to
cut down salt intake makes sense. (#800J
California Department of Health Services Director
Kenneth Kizer underscores the point that follow-up
is an essential component of screening programs. He
cites 1983 data that 90 percent of California adults
had their blood pressure measured in the previous
two-year period, but of those referred for evaluation
and diagnosis, many do not complete the referral.
Among those diagnosed and under treatment, many
do not adhere strictly to the treatment plan and
remain uncontrolled. Only a small fraction of hyper-
tensive adults are achieving and maintaining control
of their blood pressure levels, according to Kizer. As
a result of these figures, the thrust of California's
hypertension control program is enrolling and main-
taining hypertensive individuals in a health care
setting that promotes adherence to control programs.
(#591J
The American Association of Occupational Health
Nurses emphasizes worksite intervention and cites
more optimistic figures.
The worksite is an ideal place for screening,
education, intervention and prevention services.
Employers benefit from decreased incidence or
early detection of chronic health problems
through reduced health insurance and disability
costs and reduced absenteeism. Providing ser-
vices at the worksite is cost effective and offers
opportunities for increased compliance and
better treatment outcomes. A recent review of
several worksite hypertension control programs
documented that 88 to 90 percent of hyperten-
sion employees treated at the worksite con-
trolled their blood pressure. The success of
these programs, which included detection, refer-
ral, treatment and follow-up, rested strongly
upon the skills of the health care providers-
primarily nurses. (~558)
182 Healthy People 2000: Citizens Chart the Course
HIGH BLOOD CHOLESTEROL
Additional testimony on reducing serum cholesterol
focused on limiting the intake of both dietary fat and
dietary cholesterol, and as a secondary preventive
measure, on expanding screening programs to identify
individuals with high cholesterol or specific dietary
goals.
The American Heart Association reports that a
certain amount of cholesterol is necessary in the body
for building cell walls and other functions, but the
liver supplies sufficient cholesterol to meet all of the
body's own needs. (#636) Joseph Stokes of Boston
University says that an average total cholesterol value
of 190 milligrams per deciliter in adults more than 18
years old is a realistic goal for the year 2000. (~627)
Many studies have related dietary fat and choles-
terol to blood cholesterol, and blood cholesterol to
cardiovascular disease. Because of this, the AHA re-
commends monitoring personal consumption of cho-
lesterol and keeping it less than 100 milligrams per
1,000 calories in the diet, not to exceed 300 mil-
ligrams per day.3 (~636)
Stokes also favors incorporating the AHA dietary
guidelines for fat into the Year 2000 Health Objec-
tives. He says that the percentage of calories from fat
should be less than 30 percent; the percentage of
calories from saturated fat should be less than 10
percent; and the ratio between polyunsaturated and
saturated fatty acids in the diet should be ap-
pro~mately 1:1. (#627)
Leslie VanDermeer, an occupational health nurse,
says that screening of serum cholesterol levels should
be available to all employees working at a company
with a medical unit or a nursing department on the
premises. (~217)
Other witnesses also emphasized the importance of
follow-up of those with high cholesterol readings.
The American Heart Association testimony calls for
federal funds to help states develop and implement
cholesterol screening programs. It emphasizes that
such programs must involve not only screening but
also appropriate referral and treatment activities.
(#636)
Several witnesses referred to the need for in-
dividuals to reduce their fat and cholesterol intake.
Several also favored additional research into the link
between diet and cholesterol.
Witnesses also endorsed efforts to increase the
OCR for page 183
percentage of food products that are labeled according
to their fat and cholesterol content. Dietitian Marilyn
Guthrie says that the food industry should cooperate
not only in labeling food, but also in lowering the
amount of fat, saturated fat, and cholesterol in the
products. She also recommends more support for
businesses to offer cholesterol-lowering programs.
Better data on the cost versus benefits of initiating
dietary changes could provide the impetus for more
structured programs. (#077) Chapter 12 contains a
more detailed discussion of nutrition and cholesterol
control.
TARGET POPULATIONS
Many witnesses emphasized the need to develop ob-
jectives to target high-risk groups and those who are
especially hard to reach. These include Blacks,
Hispanics, the elderly, males, and children, along with
the medically or economically disadvantaged. Also, in
many instances, individuals fall into two or more of
these categories, multiplying many times the problems
faced in changing their lifestyles or getting them into
and maintaining treatment. For example, Kizer says
that data from two statewide surveys in California
demonstrate that priority must be given to ethnic
minorities with a high prevalence of hypertension and
to the medically or economically disadvantaged. He
believes that adult males within these groups, in
particular, should be targeted. (#591)
Blacks
Michael Jarrett of the South Carolina Department of
Health and Environmental Control says the Year 2000
Health Objectives should specifically address aware-
ness among high-risk groups such as Black males.
(~108) John Thomas and William Neser of Meharry
Medical College also emphasize the increased preva-
lence of hypertension among Blacks and note that
although dramatic decreases in cardiovascular disease
and hypertension have occurred in the overall popula-
tion, the Black community has not seen that kind of
decline. Possible risk factors for all groups, according
to Thomas and Neser, are parental hypertension,
weight gain, and smoking. Weight control, they em-
phasize, is an important nonpharmacological risk
reduction measure. (i#961)
Hispanics
Studies have shown that although Hispanics may have
a better general knowledge about hypertension than
Blacks, they still lag behind Whites in the percentage
of known hypertensives who are taking medication
and whose hypertension is under control.4 Crawford
speaks of the high cholesterol levels among Hispanics
in San Antonio. The problem is more pronounced in
Hispanics than in non-Hispanic Whites across socio-
economic groups. According to a local study among
those with elevated cholesterol levels, fewer Hispanics
are aware of it than non-Hispanic Whites, he testified.
Of those in both groups who are aware, only one-
fourth are under treatment and, of these, only about
40 percent have their levels controlled. Crawford
believes that the problem with high cholesterol may
be partially responsible for Hispanics not experiencing
the kind of decline in ischemic heart disease seen in
the general population in recent years. He called for
an objective to reduce the prevalence of moderate-
to high-risk cholesterol levels among young Hispanic
men. (#743)
Elderly
The elderly are at special risk for CVD, according to
Rosalie Young of Wayne State University: "As a ma-
jor killer and disabler of the elderly, heart disease
accounts for 45 percent of the mortality, 18 percent
of the hospital days, another 18 percent of the bed
days, and 10 percent of physician visits of the 65-plus
cohort.n Research she conducted for the National
Institute of Aging indicates that it also "takes a major
toll on the patient's general well being and mental
health, and produces substantial physical and mental
strain among family caregivers." (~478J
A special focus on the elderly is necessary, accor-
ding to Rebecca Richards who conducts a wellness
program for older adults in Wisconsin. She favors
adding an objective to increase public and profes-
sional awareness about the risks and appropriate
management of hypertension in older adults. Hyper-
tension is the leading reason for doctor YiSitS among
older adults in Wisconsin, but many physicians still
resist treating older people; she cited Cassel and
Walsh on the subject: "lithe dogmas that hypertension
is a benign disease in old age, that it is a natural
Cardiovascular Disease 183
OCR for page 184
result of aging, that old people need higher blood
pressure to perfuse aging organ systems, and that
antihypertensive therapy is of no value and too
dangerous in persons over 65 years of age are all too
frequently heard.l's (#183)
Children
Although several witnesses discussed the apparent
relationship between the existence of CVD risk factors
in children or teens and later manifestation of the
disease, agreement was not reached on how to identify
and treat them.
Thomas and Neser discuss a study which found
that hypertension and weight gain or smoking among
Black parents are Significant independent predictors
of hypertension among their children; they suggest
that "if such individuals were detected during early
childhood (5-6 years), intervention could be instituted
that could prevent or alter the course of later hyper-
tension and thus morbidity and deaths due to hyper-
tension and atherosclerotic cardiovascular disease."
(~261)
However, Darwin Labarthe of the University of
Texas Health Science Center at Houston warned that
it may be difficult to identify those who will be at
high risk in adulthood based on blood pressure or
cholesterol levels in adolescence because patterns are
not consistent. Cross-sectional survey data from
around the world suggest that blood pressure rises
during childhood and adolescence, and cholesterol
level falls, he says. Therefore, it may not be possible
to target individuals for prevention strategies at an
early age. (#299)
Richard Niwinski, Terry Davis, and Rosemary
Yancheck of Chapman College state that even if chil-
dren at risk could be identified, some strategies, such
REFERENCES
as dietary interventions, might not be worthwhile
because "not enough data has been collected to show
the effect of diet in the age groups from two to
twenty-~ve years." Rather, they suggest that educa-
tional programs for the parents of these children be
considered. (#182)
Labarthe says the Southwest Center for Prevention
Research is conducting research at the University of
Texas that may help determine appropriate inteIven-
tions for teenagers. (~299)
IMPLEMENTATION
The implementation issue that arose most often was
lack of funding for research, evaluation, and surveil-
lance.
The American Heart Association calls for objec-
tives that reflect the need for the federal government
to continue to dedicate "sufficient funding" to research
in cardiovascular disease, Because it is only through
continued research that disease prevention and health
promotion activities will prosper." (~636) Similarly,
the American College of Cardiology proposes objec-
tives emphasizing research on cardiovascular disease
prevention and application in practice, as well as
more physician education in primary and secondary
prevention. (#552J
Richards says that the ability to comply with
antihypertensive medication is a special problem with
older people and urges that surveillance and evalua-
tion research include older subjects. (#183) Noting
that his information collection and client tracking
systems have been "deemphasized due to lack of funds
and diminished resources," Stephen McDonough of
the North Dakota State Department of Health and
Consolidated Laboratories indicates that he is thus
less able to assess categories of high blood pressure
control. (#479)
1. U.S. Department of Health and Human SeIvices: Prevention '86787: Federal Programs and Progress.
Washington, D.C.: U.S. Government Printing Office, 1987
2. American Heart Association: Position statement: Dietary guidelines for healthy American adults. A statement
for physicians and health practitioners by the nutrition committee. Circulation 77~3~:721A-724A, 1988
3. Ibid.
4. Barrios E, Iler E, Mulloy K, et al.: Hypertension in the Hispanic and Black population in New York City. J
Nat Med Assoc 79~7~:749-752, 1987
184 Healthy People 2000: Citizens Chart the Course
OCR for page 185
5. McDonald WJ: Medical, psychiatric and pharmacological topics. Geriatric Medicine, Vol. I. Edited by CK
Cassel7 JR Walsh. New York: Springer-Verlag' 1984
TESTIFIERS CITED IN CHAPTER 24
077 Guthrie, Marilyn; Virginia Mason Clinic (Seattle)
082 Hanneman, Richard; Salt Institute
108 Jarrett, Michael; South Carolina Department of Health and Environmental Control
182 Niwinski, Richard; Davis, Terry; Yancheck, Rosemary; Chapman College (San Diego)
183 Richards, Rebecca; North Woods Health Careers Consortium (Wausau, Wisconsin)
217 VanDermeer, Leslie; Hunter College (New York
261 Thomas, John and Neser, William; diehard Medical College
299 Labarthe, Darwin; University of Texas Health Science Center at Houston
478 Young, Rosalie; Wayne State University
479 McDonough, Stephen; North Dakota State Department of Health and Consolidated Laboratories
552 Klocke, Francis; American College of Cardiology
558 Babbitz, Matilda; American Association of Occupational Health Nurses
591 Kizer, Kenneth; California Department of Health Services
627 Stokes, III, Joseph; Boston University
636 Ballin, Scott; American Heart Association
743 Crawford, Michael; University of Texas Health Science Center at San Antonio
800 Stoto, Michael; Institute of Medicine
Cardiovascular Disease 185
Representative terms from entire chapter:
cardiovascular disease
