AHA Guide for Improving Cardiovascular Health at the Community Level; A Call to Action for Healthcare Providers, Public Health Practitioners and Policy Makers
Disclosure: Dr. Stuart Shor has nothing to disclose.
Pub Date: Thursday, March 21, 2013
Author: Eileen M. Stuart-Shor, PhD, ANP, FAHA
Affiliation: University of Massachusetts Boston, College of Nursing and Health Sciences; Beth Israel Deaconess Medical Center, Boston MA.
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.
With the release of the 2013 update of the AHA Guide for Improving Cardiovascular Health at the Community Level1 the members of the writing group challenge healthcare providers, public health practitioners and policy makers to take action and implement best practice strategies at the community level. They acknowledge the array of programs and policies that have been put in place over the past few years across diverse communities and critique that literature to determine best practices which encourage cardiovascular health behaviors and health factors across populations.
The 2013 Guide redefines risk factors and risk behaviors as health factors and health behaviors in keeping with the overall goal of preventing the onset and progression of CVD and stroke (primary and secondary prevention) and maintaining optimal cardiovascular health (primordial prevention) across broader segments of the population and across the lifespan.1 The paper advances previous guidelines by “incorporating new evidence for community interventions gained over the last decade, expanding the target audience to include a broader range of community advocates, aligning with the concepts and terminology of the AHA 2020 Impact Goals,2 and recognizing the contributions of new public and private sector programs involving community interventions”.1
The AHA Community Guide has taken an important step by highlighting the importance of the social determinants of health (figure 1). The social and environmental origins of CVD have long been recognized, but specific strategies to address these influences have been ellusive. The authors affirm the importance of maintaining healthy lifestyle behaviors, but acknowledge the contribution of the built environment to facilitate or challenge the adoption and maintenance of healthy lifestyle behaviors. In addition, the writing group places the issue in the realm of social justice encouraging communities to “implement community-wide interventions that are socially and culturally appropriate in order to reduce disparities and inequities in the cardiovascular health of socioeconomically disadvantaged subgroups”. 1
In order to achieve the goal of CVD prevention the authors scaffold the community-wide approaches in three intersecting domains: 1) the optimal behaviors targeted for population-wide change, 2) the community setting targeted for intervention, and 3) the public health interventions required for population–wide changes to improve cardiovascular health (Figure 2).1 Thus, achieving the population and individual goal of “no smoking” necessities surveillance, public education (media), organizational partnerships, integration of individual level interventions in the healthcare system and policy/environmental changes at all levels of the lived experience (schools, religious organizations, healthcare facilities and worksites). This rubric of intersecting and inter-related factors acknowledges the complexity of implementing and maintaining healthy behaviors while proposing a framework to successfully implement health promoting strategies.
This document comes at a critical juncture in the drive to promote optimal cardiovascular health and eliminate disparities in cardiovascular outcomes across populations. In the recently released Heart Disease and Stroke Statistics – 2013 Update, Go and colleagues note the persistence of adverse lifestyle behaviors and disparities in outcomes.3 Selected examples include:
- Despite 4 decades of progress, among Americans ≥ 18 years of age, 21.3% of men and 16.7% of women continue to be cigarette smokers.
- 32% of adults reported engaging in no aerobic leisure-time physical activity.
- The proportion of youth (≤ 18 years of age) who report engaging in no regular physical activity is high and the proportion increases with age.
- Between 1971 and 2004 average total energy consumption among US adults increased.
- The estimated prevalence of overweight and obesity in US adults ≥ 20 years of age is high (68%)
- Among children 2 to 19 years of age 31.8% are overweight and obese.
- The prevalence of diabetes mellitus is increasing dramatically over time, in parallel with the increases in prevalence of overweight and obesity.
- African Americans, Mexican Americans, Hispanic/Latino individuals and other ethnic minorities bear a disproportionate burden of diabetes mellitus.
- African Americans have the highest prevalence of hypertension (44%) in the world.
- Only 53% of those with documented hypertension have their condition controlled to target levels.
- African Americans have a higher incidence of death attributable to CVD.
Addressing these persistent health problems and disparities necessitates a population-based community-wide approach to improving the circumstances in which people are born, grow, live, work and age. It requires attention to the social determinants of health and not just the bio-behavioral causes of disease. It requires healthcare providers to join with colleagues in public health and health policy to effect evidence-based strategies at the population level and to tackle the inequitable distribution of resources; the structural drivers of conditions of daily life and the way we access health services. And it requires a continued commitment to measure the problem, evaluate action and expand the knowledge base.4 The AHA Guide to Improving Cardiovascular Health at the Community Level integrates a theoretical framework for population-wide CV risk reduction (figures 1 and 2) and provides evidence based strategies , intervention goals and recommended actions (table 1-4). If we are to realize the goal of improving the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20% 2, and eliminating disparities in CVD and stroke outcomes for racial/ethnic minorities, the onus is on each of us to act on this information.
Knowing is not enough; we must apply. Willing is not enough; we must do. (Johann Wolfgang von Goethe).
- 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.
- Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow GC, Ho PM,
Lauer MS, Masoudi FA, Robertson RM, Roger V, Schwamm LH, Sorlie P, Yancy CW, Rosamond WD. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation. 2010;121:586-613.
- Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Magid D, Marcus GM, Marelli A, Matchar DB, McGuire D, Mohler E, Moy CS, Mussolino ME, Nichol G, Paynter NP, Schreiner PJ, Sorlie PD, Stein J, Turan TN, Virani SS, Wong ND, Woo D, Turner MB; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013; 127: e6-e245. 10.1161/CIR.0b013e31828124ad
- Marmot MG, Bell R. Action on Health Disparities in the United States: Commission on Social Determinants of Health. JAMA. 2009;301(11): 1169-1171.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association