State of New York: Cardiovascular Health in New York State: A Plan for 2004 – 2010

Executive Summary

Cardiovascular disease (CVD) remains the leading cause of death in the United States despite improvements in prevention, detection, and treatment of cardiovascular disease. Its impact is staggering. About 950,000 Americans die each year and 61 million, or one quarter of the population, live with the disease. In 1999, over 70,700 New Yorkers died of some form of cardiovascular disease.

The profile of who is at risk is changing. CVD is no longer a disease that primarily affects men as they age. It has become a killer of people in the prime of life, with more than half of all deaths occurring among women. Specific segments of the population are at greater risk than others. In 1999, death rates from stroke were 29% higher among Black men than White men, and 49% higher for Black women than White women. This disparity is attributed primarily to a higher incidence of significant risk factors, namely hypertension and diabetes.

After years of health promotion targeting individuals, the public health community has learned that the environment in which a person lives and works plays a role in health behavior. The New York State Cardiovascular Health Plan is grounded in this new understanding; that is, in giving attention not only to the behavior of individuals but also to the environments in which they live.

This plan is a call-to-action to address the epidemic of obesity, sedentary lifestyles and tobacco use, the unacceptable levels of blood pressure, diabetes, and cholesterol, and the continuing disparities in health outcomes in specific populations. Adhering to principles of community involvement and engagement, multiple partners were enlisted to collaborate at the state, regional and local levels to address the key sectors in our society: schools, communities, worksites and health care settings. Identifying these sectors directs efforts at reducing cardiovascular health risks to settings where people spend a considerable part of their waking days. The sector focus provides opportunities to start and sustain policies and programs that will lead to healthy lifestyles and improved cardiovascular health.

New York State’s Plan for Cardiovascular Health was developed through the input and advice of a diverse group of experts from across the state. The workgroup included specialists from medicine and health care, business leaders, educators, public health professionals at both the local and state levels, as well as representatives from other state agencies with interest in cardiovascular health. Throughout the summer of 2002, the experts worked in subcommittees to develop the goals, objectives and suggested strategies outlined in the four sector-based reports. Our next steps will be to engage the interest and commitment from potential partners and stakeholders to implement the New York State Cardiovascular Health Plan.

The objectives of the workgroup emphasize the early risk factors for heart disease and stroke – physical inactivity, poor diet and tobacco use. All reports except the health care sector discuss actions steps needed to get people to quit smoking, eat the right amounts of healthy foods, and be more physically active. Stakeholders in health care settings are encouraged to follow the appropriate clinical guidelines for CVD-related diagnoses, to develop more efficient, team approaches to emergencies and to promote healthy lifestyles among people they serve.

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Introduction

Cardiovascular disease (CVD) remains the leading cause of death in the United States despite improvements in prevention, detection, and treatment. The profile of individuals at risk is changing. CVD is no longer thought of as a disease that primarily affects men as they age. It is a killer of people in the prime of life, with more than half of all deaths occurring among women. Specific segments of the population are at greater risk than others. In 1999, national death rates from stroke were 29% higher among Black men than White men, and 49% higher for Black women than White women. This disparity is attributed primarily to a higher incidence of significant risk factors, namely hypertension and diabetes.

Cardiovascular diseases remain the leading cause of disability among working adults. Stroke alone accounts for the disability of more than a million Americans. The economic impact on the health system grows larger as the population ages. In 2001, the estimated cost of health care expenditures and lost productivity attributable to cardiovascular diseases was $298 billion.

Studies conducted in the United States and elsewhere in the world demonstrate the impact of healthy community environments on the cardiovascular health. Effective approaches include altering physical environments and making policy changes at schools, worksites, restaurants, cafeterias, health care and other settings. These changes promote, enable and reinforce healthy behaviors. Also important are communication strategies that educate citizens, policy-makers, health care professionals and others about how to achieve cardiovascular health.

After years of targeting individuals with health promotion campaigns, the public health community has modified its understanding of how behaviors change. The New York State Cardiovascular Health Plan is grounded in this expanded approach; that is, in giving attention not only to the behavior of individuals but also to the environments in which they live. Experience suggests the most successful strategies implement concurrent changes in environments, systems, and policies at the family, community, organization, and societal levels.

This plan is a call to action to address the epidemic of obesity, sedentary lifestyles and tobacco use, the unacceptable levels of blood pressure, diabetes, and cholesterol, and the continuing disparities in health outcomes in specific populations. Adhering to principles of community involvement and engagement, multiple partners were enlisted to collaborate at the state, regional and local levels to address key sectors in our society.

Policy, public awareness and services will be addressed in each sector. The plan’s objectives are rooted in Healthy People 2010 as well as baseline measures taken from data sources unique to New York State.

The over arching objective of this plan is to effect cardiovascular disease by expanding heart healthy environmental and policy supports in four sectors (schools, worksites, communities and health care settings). The task for cardiovascular health partners over the next several years is to build on existing primary, secondary and tertiary CVD prevention efforts at the state, community and local levels.

Several New York State Department of Health programs have developed state plans addressing some of the same risk factors and environmental issues addressed in this plan. Where there is commonality among action steps in the plans, collaboration with these other programs will be a priority.

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A Vision for Cardiovascular Health for New York State

The vision of this plan’s developers for New York State is one of communities in which homes, neighborhoods, schools, workplaces and health care environments promote and sustain cardiovascular health. In an ideal healthy community, people walk or bicycle whenever they can; physical activity is safe, inviting and commonplace. There are farmers markets every week in season. People eat fruits and vegetables at every meal and include them in snacks. Restaurants offer healthy meal choices with reasonably sized portions. Children have organized physical activity every day at school. There are only healthy, tasty, nutritious foods served in school cafeterias and on school property. Worksites encourage physical activity as a way to reduce stress and improve overall health. Healthy food is available to workers in the community and at the worksite. Physicians and other health professionals discuss, advise and help their patients adopt healthy behaviors, such as eating healthfully and staying active. People with cardiovascular disease will receive evidence-based treatment by a team of health professionals, including a physician, nurse practitioner or physician assistant as the team leader under the direction of a physician, collaborating with specialists such as cardiologists, neurologists, dietitians and psychologists.

This vision is consistent with the recently released Public Health Action Plan for Cardiovascular Health, developed and embraced by key partners at the national and state level, public health experts, and heart disease and stroke prevention specialists1. The national plan, developed through a process convened by the Centers for Disease Control and Prevention and its parent agency, the Department of Health and Human Services, presents targeted recommendations and action steps for the nation to address the Healthy People 2010 goal of improving cardiovascular health through:

  • Prevention, detection, and treatment of risk factors;
  • Early identification and treatment of heart attacks and strokes; and,
  • Prevention of recurrent cardiovascular events.

The following principles will guide New York State partners’ work in cardiovascular health promotion and disease prevention:

  • Heart disease and stroke are recognized as the leading killers in New York State;
  • Use of science, technology and appropriate surveillance and data analysis will guide the work;
  • Prevention and management of risk factors will reduce the occurrence of cardiovascular diseases;
  • Work will focus on high-risk populations; and,
  • A comprehensive approach to reduce the burden of CVD will recognize the many and diverse risk factors that affect cardiovascular health.

This plan provides a framework and action steps to achieve a vision in which cardiovascular diseases are no longer inevitable consequences of aging, where people can expect to live in heart healthy and stroke-free communities. Plan objectives are aimed in four sectors – schools, communities, worksites and health care settings. These sectors allow work to occur in settings where people spend a considerable part of their waking days. They provide opportunities to start and to sustain policies and programs that will lead to healthy lifestyles and improved cardiovascular health.

These recommendations are based on the best available science and the most promising interventions for population-wide impact. To accomplish the objectives set forth in this plan, a commitment is needed from all New Yorkers to do what is possible to reverse the epidemic of cardiovascular disease.

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National Overview

Cardiovascular disease (CVD) was the cause of 39.4% of all deaths, or two out of every five deaths in the United States in 2000, according to the American Heart Association’s “Heart Disease and Stroke Statistics – A 2003 Update.” Since 1900, CVD has been the leading cause of death every year except 1918. One in five people in the United States has some form of cardiovascular disease. These diseases claim more lives than the next five leading causes of death combined (cancer, chronic lower respiratory diseases, injuries, diabetes and influenza/pneumonia).2

In 1999, $26.3 billion were spent for the hospitalization costs of Medicare beneficiaries receiving treatment for cardiovascular problems, an average of $7,883 per discharge. Nationwide, in 2002, almost $130 billion was spent on the direct and indirect costs of coronary heart disease.3

Research that may help reduce the current epidemic in CVD is underway on many fronts. New, non-invasive methods of diagnosing circulatory problems are being investigated. Blood tests to identify high levels of certain proteins are under investigation as early markers of heart disease. Genetic information and detailed family histories will help future clinicians identify patients at high risk for heart disease or stroke and take early action. Improvements in the medical and surgical treatment of CVD continue to provide a hopeful future for individuals suffering debilitating heart failure or coronary artery disease.

Medical breakthroughs bring a promise of hope to suffering CVD patients. However, the high costs of pharmaceutical and surgical treatments could be reduced if Americans were to eat healthier diets, be active every day, and stop smoking. The baseline information from the national Behavior Risk Factor and Surveillance System4 suggests the need for significant behavior change:

  • Nearly 23% of adult Americans currently smoke, a figure that has not decreased for at least 10 years (2002);
  • Over one-quarter of Americans reported having no leisure time physical activity (2001);
  • Three-quarters of Americans do not eat the recommended number of servings of fruits and vegetables each day (2002); and,
  • Over 37% of all Americans are overweight – BMI between 25 and 29.9 kg/m2- and an additional 21% are obese – BMI of 30 kg/m2or greater (2002).
  • More than 60 million Americans have some form of CVD, including high blood pressure, coronary heart disease, stroke, congestive heart failure, or other conditions (1999).
  • It is estimated that approximately 50,000,000 Americans have high blood pressure.5

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CVD in New York State: Current Status

Cardiovascular diseases, including heart disease and stroke, are the leading causes of death in New York State, killing more than 70,000 residents each year. For every person who dies from a heart attack or angina, 18 people live with these conditions. For every person who dies from a stroke, seven people cope with the consequences of a non-fatal event6. Many of these survivors are disabled and cannot lead productive lives. They also are at high risk for additional events. Furthermore, these numbers are increasing as the epidemic of heart disease and stroke continues. Growing disparities in health have contributed to a much higher toll in some population groups.

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National Policies

According to the Centers for Disease Control and Prevention (CDC), every state health department should have the capacity, commitment, and resources7 to carry out a comprehensive cardiovascular health promotion, disease prevention and control program to improve the cardiovascular health of all Americans.

“State health departments are uniquely qualified to define the cardiovascular disease problem throughout the State, to plan and develop statewide strategies to reduce the burden of CVD, to provide overall State coordination of cardiovascular health promotion, disease prevention, and control activities among partners, lead and direct communities, to direct and oversee interventions within overarching State policies, and to monitor critical aspects of CVD.”

Since 1998, Congress has provided funding to CDC for a national, state-based cardiovascular disease prevention program. New York State is one of 30 states funded to address cardiovascular health issues. The essential components of CDC-funded activities have been: definition of the cardiovascular disease problem within the State; development of partnerships and coordination among concerned non-governmental and governmental partners; development of effective strategies to reduce the burden of cardiovascular diseases and related risk factors with an overarching emphasis on health policies and physical and social environmental changes at all levels as interventions; development of population-based interventions to address primary and secondary prevention, and monitoring of critical aspects of cardiovascular diseases.

New York State’s Cardiovascular Health Plan works within the national framework set by CDC. Efforts by both governmental and non-governmental partners will be needed to develop, or change, policies at state and local levels that will provide New Yorkers with opportunities to be heart healthy and stroke-free. Interventions should be carried out on three levels for cardiovascular health:

  • Health Promotion

Promote healthy behaviors and lifestyles to encourage New Yorkers to be physically active, eat healthfully and be smoke-free.

  • Primary Prevention

Assure that individuals diagnosed with hypertension, high blood cholesterol, diabetes and obesity receive appropriate and successful treatment through activities such as professional education, promotion of disease management programs, and special focus on these populations in health promotion programs.

  • Secondary Prevention

Hospitals, health plans and other professional organizations and groups work to assure appropriate care and rehabilitation for New Yorkers who have already experienced a stroke or a heart attack.

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Cardiovascular Disease Risk Factors

Risk factors are conditions or behaviors that increase the likelihood of developing a disease. Having more than one risk factor for heart disease or stroke greatly multiplies risk. Tobacco use, physical inactivity, poor nutrition, obesity, hypertension, high blood cholesterol, and diabetes are known, modifiable risk factors for CVD. Through smoking cessation, increased exercise, and improved nutrition, people can lower their blood pressure and blood cholesterol levels, and reduce obesity, thereby lowering their risk for heart disease and stroke. For people who have already suffered a cardiovascular event, adopting healthier behaviors will reduce their risk of subsequent events.

Tobacco Use

Risk

Tobacco use is the number one preventable cause of death in our society8 and is responsible for a substantial share of the burden of cardiovascular disease. Cigarette smoking is the biggest risk factor for sudden cardiac death (smokers have two to four times the risk of nonsmokers), and is an important risk factor for stroke. Evidence also indicates that chronic exposure to environmental tobacco smoke (secondhand smoke, passive smoking) may increase the risk of heart disease.

Smoking increases blood pressure, decreases exercise tolerance and increases the tendency for blood to clot. It increases LDL (bad) cholesterol and decreases HDL (good) cholesterol.9 Smoking also exacerbates other risk factors such as hypertension, diabetes or obesity.

Benefits to smoking cessation

Eliminating tobacco use has immediate benefits to cardiovascular health. Just 20 minutes after finishing a cigarette, blood pressure and pulse rate return to normal and heartbeat becomes stable. Eight hours after quitting, oxygen levels rise and carbon monoxide is removed from the lungs. Three months after quitting, circulation improves and blood flows through the body more easily. In one year, the risk of dying from a heart attack is cut in half. In five years, the risk of a stroke has become that of a non-smoker.10

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Physical Inactivity

Risk

The risk for coronary heart disease associated with physical inactivity is similar to that of cigarette smoking. In a 1993 study, 14% of all deaths in the United States were attributed to low patterns of activity and poor diet.11 Another study linked sedentary lifestyles to 23% of deaths from major chronic diseases.12

According to Behavioral Risk Factor Surveillance System (BRFSS) data, 30% of the adult population is physically inactive. Inactivity increases with age and is substantially higher in the 65 and older group; Blacks and Hispanics are significantly less likely to be active than Whites; and both income and education displayed a reverse relationship with physical inactivity, as income and education increased, the rate of physical inactivity decreased.

Benefits of Physical Activity

Regular physical activity is critically important for the health and well being of people of all ages. Research has demonstrated that virtually all individuals can benefit from regular activity, whether they participate in vigorous exercise or some type of moderate health-enhancing physical activity. Even among frail and very old adults, mobility and functioning can be improved through physical activity.13

According to the CDC, regular physical activity performed on most days of the week reduces the risk of developing or dying from some of the leading causes of illness and death in the United States.

Regular physical activity improves health in the following ways:

  • Reduces the risk of dying prematurely;
  • Reduces the risk of dying from heart disease;
  • Reduces the risk of developing diabetes and high blood pressure;
  • Helps reduce blood pressure in people who already have high blood pressure;
  • Reduces feelings of depression and anxiety;
  • Helps control weight;
  • Helps build and maintain healthy bones, muscles, and joints;
  • Helps older adults become stronger and better able to move about without falling; and,
  • Promotes psychological well-being.

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Inadequate Nutrition

Risk of poor nutrition

Poor diet can lead to many cardiovascular health problems, especially high blood cholesterol levels, obesity and diabetes. Diets too high in calories combined with inadequate physical activity have fueled an epidemic of obesity and a dramatic rise in the prevalence of diabetes.

Benefits of a healthy diet

A diet low in saturated fat and calories has been shown to reduce the risk of cardiovascular disease. Lifestyle changes, including dietary factors, have great potential in reducing mortality and morbidity associated with CVD. Studies demonstrate that people who ate the most fiber (average 21 grams/day) had a greater than 10% and 35% reduction in coronary heart disease and ischemic stroke, respectively, than those who ate the least fiber (average 5 grams/day).14 Another study found that legume consumption four times or more per week compared with less than once a week was associated with a 22% lower risk of coronary heart disease and an 11% lower risk of CVD.15 Increasing consumption of fruit, vegetables, and whole grains and choosing foods low in saturated fat will reduce the risk of CVD. There is a diverse array of substances in fruits and vegetables associated with decreased risk of CVD including antioxidants, folate, fiber, potassium, flavonoids, and other phytochemicals. A number of reports have shown a beneficial effect of fruit and vegetable consumption on risk of CVD and recent prospective studies have added to the growing evidence that fruit and vegetable intake reduces risk factors as well as incidence and mortality associated with CVD.16

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Overweight and Obesity

Risk

According to CDC, overweight refers to increased body weight in relation to height, when compared to a standard of acceptable or desirable weight. Obesity is defined as an excessively high amount of body fat or adipose tissue in relation to lean body mass. Obesity is one of the most serious health problems facing both children and adults of our state. Overweight (Body Mass Index of 25 to 29.9 kg/m2) and obese individuals (BMI of 30 kg/m2 and above) are at increased risk for physical ailments such as:17

  • High blood pressure, or hypertension;
  • High blood cholesterol levels;
  • Type 2 (non-insulin dependent) diabetes mellitus;
  • Insulin resistance, or glucose intolerance;
  • Coronary heart disease;
  • Angina pectoris;
  • Congestive heart failure;
  • Stroke; and,
  • Other non-CVD-related health problems.

Benefits of weight control

There is strong evidence that weight loss by overweight and obese individuals reduces their risk for diabetes and cardiovascular disease. Weight loss reduces blood pressure in both overweight hypertensive and non-hypertensive individuals; reduces serum triglycerides and increases high-density lipoprotein cholesterol (HDL) levels; and generally produces some reduction in total serum cholesterol and low-density lipoprotein cholesterol (LDL) levels.

According to the U.S. Surgeon General:18

  • Weight loss, as modest as 5 to 15% of total body weight, in a person who is overweight or obese, reduces the risk factors for some diseases, particularly heart disease.
  • Weight loss can result in lower blood pressure, lower blood sugar, and improved cholesterol levels.

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High Blood Pressure

Risk

Blood pressure is the force of blood against the walls of arteries. It rises and falls throughout the day. When the pressure stays elevated over time, it is called high blood pressure.

The medical term for high blood pressure is hypertension. Hypertension is dangerous because it makes the heart work too hard thereby increasing the risk of heart attack and stroke, the first- and third-leading causes of death among Americans. High blood pressure also can result in other conditions, such as congestive heart failure, kidney disease, and blindness.

Combined with other risk factors such as poor diet, high cholesterol levels, overweight, diabetes, and physical inactivity, the risk from high blood pressure increases several times. In 1999, nearly 23% of the population self reported high blood pressure. The highest rates were noted in Blacks and the lowest noted by those in the highest income and education categories. Prevalence of high blood pressure also increases with age. Forty-two percent of those over 65 suffer from this condition.

According to the National Heart Lung and Blood Institute, hypertension is the most common primary diagnosis in America (35 million office visits as the primary diagnosis).19 Current control rates (systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg), though improved, are still far below the Healthy People 2010 goal of 50 percent; 30 percent are still unaware they have hypertension. In the majority of patients, controlling systolic hypertension, which is a more important CVD risk factor than diastolic blood pressure except in patients younger than age 50,20 and occurs much more commonly in older persons, has been considerably more difficult than controlling diastolic hypertension. Recent clinical trials have demonstrated that effective blood pressure control can be achieved in most patients who are hypertensive, but the majority will require two or more antihypertensive drugs. When clinicians fail to prescribe lifestyle modifications, adequate antihypertensive drug doses, or appropriate drug combinations, inadequate blood pressure control may result.21

Hypertension classifications have changed recently. The following table outlines the most current classifications, according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

BP Classification Systolic mm Hg Diastolic mm Hg
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension >160 or >100

Maintaining Healthy Blood Pressure

High blood pressure can be prevented and controlled in a number of ways. Recommendations for the maintenance of healthy blood pressure include:

  • Have blood pressure checked at least once a year;
  • Maintain a healthy weight;
  • Be physically active; 30 minutes of moderate-level physical activity on most, and preferably all, days of the week;
  • Follow a healthy eating plan, including foods lower in salt and sodium. Have no more than 2,400 milligrams of sodium (6 grams of salt) a day;
  • Consume alcoholic beverages in moderation; alcohol in excess has been shown to drive up blood pressure; and,
  • Take prescribed high blood pressure medication as directed.

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High Blood Cholesterol

Risk

Blood cholesterol levels play an important part in determining the chance of developing coronary heart disease (CHD). The higher the blood cholesterol level is, the greater the risk. Cholesterol is a waxy substance found in all parts of the body. When there is too much cholesterol in the blood, the excess builds up on the walls of the arteries that carry blood to the heart. This buildup is called “atherosclerosis” or “hardening of the arteries.” It narrows the arteries and can slow down or block blood flow to the heart. With less blood, the heart gets less oxygen. Without enough oxygen to the heart, there may be chest pain (“angina” or “angina pectoris”), heart attack (“myocardial infarction”), or even death.

High blood cholesterol level by itself does not cause symptoms; many people are unaware that their cholesterol level is too high. Everyone age 20 and older should have his or her cholesterol measured at least once every 5 years. It is best to have a blood test called a “lipoprotein profile” to find out cholesterol numbers. This blood test is done after a 9 to 12 hour fast and gives information about:

  • Total cholesterol;
  • Low density lipoprotein (LDL) or bad cholesterol–the main source of cholesterol buildup and blockage in the arteries;
  • High density lipoprotein (HDL) or good cholesterol–helps keep cholesterol from building up in the arteries; and
  • Triglycerides–another form of fat in blood.

It is important to know an individual’s cholesterol levels because lowering those that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease. Cholesterol lowering is important for everyone–younger, middle age, and older adults; women and men; and people with or without heart disease.22 Treatment for high cholesterol is usually based on LDL levels as well as other risk factors. Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood. The following charts show how the National Heart, Lung & Blood Institute (NHLBI) categorizes cholesterol levels.

Total Cholesterol Level Total Cholesterol Category
Less than 200 mg/dL Desirable
200 – 239 mg/dL Borderline high
240 mg/dL and above Very high
LDL Cholesterol Level LDL Cholesterol Category
Less than 100 mg/dL Optimal
100-129 mg/dL Near optimal/above optimal
130-159 mg/dL Borderline high
160-189 mg/dL High
190 mg/dL and above Very high

HDL (good) cholesterol protects against heart disease, so for HDL, higher numbers are better. A level less than 40 mg/dL is low and is considered a major risk factor because it increases risk for developing heart disease. HDL levels of 60 mg/dL or more help to lower the risk for heart disease. Triglycerides can also raise heart disease risk. Levels that are borderline high (150-199 mg/dL) or high (200 mg/dL or more) may need treatment in some people. A high LDL combined with any of the following risk factors increases the risk of heart attack:

  • Cigarette smoking;
  • High Blood Pressure (140/90 mm Hg or higher or on blood pressure medication);
  • Low HDL cholesterol (less than 40 mg/dL);
  • Family history of early heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65); or,
  • Age (men 45 years or older; women 55 years or older).

Maintaining Healthy Serum Cholesterol Levels

Even when an individual’s blood cholesterol level is close to the desirable range, lowering it will reduce the risk of developing heart disease. Eating in a heart-healthy way, being physically active, and losing weight, for those who are overweight or obese, are things everyone can do to help lower their risk of developing heart disease.

  • Choose foods low in saturated fat, low in total fat and low in cholesterol;
  • Maintain a healthy weight, and lose weight if overweight or obese;
  • Drink fat-free or 1% milk rather than 2% or whole milk to reduce saturated fat intake;
  • Eat fruits and vegetables often: fresh, frozen, or canned. They have no cholesterol and most are low in saturated fat;
  • Eat whole-grain breads, rolls, and cereals;
  • Choose restaurants that have low fat, low cholesterol menu items; and,
  • Make physical activity part of a daily routine.

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Diabetes

Risk

The risk of CVD is much higher among individuals with diabetes. Diabetes adds to the risk of heart disease and requires monitoring of blood pressure, blood sugar and cholesterol levels to avoid complications. Individuals with diabetes should ask their physician for testing and explanation of the following:

  • Hemoglobin A1C – This measures average blood sugar levels over the last three months and should be below seven percent for most people;
  • Blood pressure – High blood pressure is particularly dangerous for diabetics. Blood pressure should be treated to keep below 130/80 mm Hg; and,
  • Cholesterol – LDL cholesterol should be below 100 mg/dl for people with diabetes.

Maintaining Cardiovascular Health for Individuals with Diabetes

People with diabetes can reduce their risk of heart disease and stroke by following the suggestions provided below:

  • Do some physical activity every day;
  • Eat less fat and less salt;
  • Eat more fiber – choose whole grains, fruits, vegetables and beans;
  • Stay at a healthy weight; lose weight if overweight or obese;
  • Stop smoking – seek help if needed;
  • Take medicines as prescribed; and,
  • Ask your doctor about taking aspirin.23

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New York State Demographics and Geography

New York State’s population of nearly nineteen million24 is comprised of geographically, culturally and ethnically diverse groups. New York City comprises about forty percent of the state’s population. The counties immediately north of New York City (Orange, Rockland and Westchester Counties) and on Long Island (Nassau and Suffolk Counties) comprise twenty-one percent of the state’s population and the remaining thirty-nine percent of New Yorkers live in the urban areas in and around Albany, Syracuse, Rochester and Buffalo, or in more rural communities.

New York State’s racial and ethnic diversity is as varied as its geography. This along with the disparity in population density poses special challenges to planning and implementation of the State Cardiovascular Health Plan. For example, population density ranges from an average of 52,808 individuals per square mile in New York County (Manhattan) to only 3 people per square mile in Hamilton County in the Adirondacks.

Non-Hispanic Whites remain the largest racial group, however, three out of every ten persons belong to one of the state’s racial or ethnic minority groups. According to the 2000 U.S. Census, NYS has the largest population of Blacks in the United States (3,014,385); is among the top eight states with Hispanic residents (2,867,583) and includes more than one million Asian/Pacific Islanders (1,053,794).

Thus, inherent to all assessment, planning, strategic planning and program development activities is the recognition of the importance of addressing the cultural and linguistic diversity of the state.

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CVD Mortality

While age-adjusted25 death rates for CVD have declined over the past 20 years, CVD continued to be the most frequent cause of death for men and women of all races in 1999. The decline has been attributed to advances in the treatment of CVD, decreased tobacco use, decreased serum cholesterol levels, and improved control of hypertension.26 Recent trends, however, threaten to reverse this decline. These include increased caloric intake, a rise in obesity rates, and large increase in the prevalence of type 2 diabetes.27 Forty-five percent of all deaths are still caused by CVD, which causes almost twice as many deaths as the next leading cause, cancer, and more deaths than from the next five causes combined.

The highest mortality lies with the oldest segments of the population. Those between the ages of 65 to 74 have a crude mortality of 926.6 per 100,000, which is twice the state rate, 388.9 per 100,000. However, CVD strikes all age groups. It is second only to cancer in affecting those between the ages of 35 and 64, one of the top five causes of death for those 25 to 34 and is one of the top ten causes of death for those under 24. Coronary heart disease is the most common cause of CVD death at all ages, while the percent of CVD deaths due to stroke and congestive heart disease increase with age.

The Leading Causes of Death in NYS, Age Distribution, 1999.*

Notes: * Source: NYS Vital Statistics, 1999

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Special Populations

Major disparities in cardiovascular disease risk exist among population groups. A disproportionate burden of death and disability from cardiovascular disease is found in minority and low-income populations. Disparities also exist in the prevalence of cardiovascular risk factors. Racial and ethnic minorities have higher rates of hypertension, tend to develop hypertension at earlier ages, and are less likely to undergo treatment to control high blood pressure. The rates of regular screening for cholesterol show disparities for certain racial and ethnic minorities as well. Consistent with Healthy People 2010, eliminating racial and ethnic disparities in health will require enhanced efforts at preventing disease, promoting health and delivering appropriate care.

The age adjusted 1999 death rate from cardiovascular disease in New York for Blacks (381 per 100,000) exceeds that of Whites by about 4% (367 per 100,000). The most pronounced differences in cardiovascular disease death rates are seen among those aged 35 to 74 years. The death rate for Blacks in this age group exceeded that of Whites by almost 30% (320 vs. 247 per 100,000, respectively) and was three times that of the other race group (320 vs. 103 per 100,000, respectively).

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Cardiovascular Disease Death (in ages 35-74), Age-Specific Mortality Rates by Race, 1999*

Notes: *Source: CDC Compressed Mortality File, 1999

According to the BRFSS data, Black adults had similar patterns of tobacco use, high cholesterol, and consumption of fruits and vegetables as Whites. However, their rates of physical inactivity, obesity, high blood pressure and diabetes all exceeded the estimates for their White counterparts. Estimates from the Youth Risk Behavior Surveillance System (YRBSS) of risk factors for youth suggested that Blacks had similar levels of moderate physical activity, and fruit and vegetable consumption, and substantially lower rates of tobacco use compared to Whites. However, Black youth had much higher rates of overweight and lower rates of vigorous physical activity than their White counterparts.

More women than men die from cardiovascular disease primarily due to women’s longer life expectancy. Almost 40,000 women died from CVD in 1999; over 100 women die each day from cardiovascular disease. While men die from CVD at younger ages than women, and mortality is higher in the older population where women make up 70% of those 85 and older, a greater number of women ultimately die of CVD than men. Therefore men have a higher rate of premature death from CVD and women have a higher death rate in older age groups.

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Age-adjusted Verses Crude Mortality Rates for Cardiovascular Disease, 1999.*

Notes: * Source: CDC Compressed Mortality File, 1999

Standard population: US 2000.

Compared to other states, New York experiences an unusually high rate of increased CVD mortality beginning at age 65. In 1999, the death rate was 42 times higher than for CVD generally and more than 44 times for coronary heart disease and stroke than for younger age groups. New York’s death rate for coronary heart disease, ages 65 and older, was 88% higher than the national rate. The greatest burden lies within the oldest segment of the population, those over 85 years old.

Older people have the same risk factors as young populations. The benefits of modifying hypertension, cessation of cigarette smoking and increased physical activity have been documented in older populations. However, there has been an upward trend in obesity among older persons, which is of concern because obesity adds additional risk of cardiovascular disease beyond other risk factors. Elevated blood pressure (42%) diabetes (15%) and high cholesterol (34.6%) increases are also notable in this group.

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Economic Impact

The cost of cardiovascular disease nationwide is now $130 billion and is projected to be much higher as the population ages.28 By following the recommendations based upon sound public health practice and clinical preventive medicine, this staggering burden could be significantly reduced. The American Heart Association developed a model to calculate the economic costs of the disease based on factors that include direct costs (hospitalizations, costs of professionals and use of pharmaceuticals) as well as indirect costs (lost productivity resulting from both morbidity and mortality). Based on this model, the total cost to New York of cardiovascular diseases in 2000 was calculated at nearly $16 billion.

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New York State Estimated Direct and Indirect Costs for Cardiovascular Diseases: 2002 (in Millions of Dollars).*

Coronary Heart Disease Stroke Congestive Heart Failure Total Cardiovascular Disease
Direct Costs
Hospital/Nursing Home $3,751.2 $1,189.2 $828.1 $6,120.9
Physicians/Other Professionals $771.8 $116.5 $86.0 $1,451.4
Drugs/Other $0.0 $0.0 $0.0 $0.0
Medical Durables $556.4 $38.8 $107.6 $1,543.6
Home Health Care $143.6 $150.5 $129.1 $567.9
Total direct expenditures $5,223.0 $1,495.0 $1,150.8 $9,683.8
Indirect Costs
Lost Productivity/Morbidity $753.8 $271.8 NA $1,499.9
Lost Productivity/Mortality## $4,056.3 $631.0 $96.8 $4,795.8
Total indirect expenditures $4,810.2 $902.9 $96.8 $6,295.7
Grand Totals $10,033.2 $2,397.9 $1,247.6 $15,979.5
Notes:
* Source: American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas, Tex.: American Heart Association; 2001.
Estimates for each grouping of CVD are established by dividing the national estimates for the disease grouping in the American Heart Association model by the proportion of New York State deaths occurring in the disease group.
## Lost future earnings of persons who will die in 2002, discounted at 4 percent.

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Background of the Plan Development Process

New York State’s Plan for Cardiovascular Health was developed through the input and advice of a diverse group of experts from across the state. (See Appendix B for list.) The workgroup included specialists from medicine and health care, business leaders, educators, public health professionals from the local and state levels, as well as representatives from other state agencies with influence and interest in cardiovascular health. These experts were provided with information about the burden of cardiovascular disease in New York, the risk factors leading to CVD, and some strategies that have been successful in other states.

The experts developed the goals, objectives and suggested strategies outlined in the four sector-based reports. They investigated the literature, consulted with other experts in the sector, and examined current practices around the country. Baseline data were collected where available. Where no baseline data were available, the subcommittee identified the need for these data in order to evaluate future work.

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Strategic Plan: Cardiovascular Health Goals and Strategies for NYS

Youth/Schools Sector

The incidence of childhood obesity, type 2 diabetes, dyslipidemia or high cholesterol and sedentary lifestyle has never been higher. Without significant modification to risky behaviors, our youth will continue these patterns into adulthood. Schools are a logical arena in which to implement comprehensive prevention strategies. It is in pre-schools, schools, and after-school programs that our children spend a significant portion of their formative years. Adding policy and environmental strategies in traditional education settings will lead to prevention programs that both model and set the stage for children to be actively involved in more heart healthy lifestyles.

The overall goal of this Action Plan is to prevent CVD in New York’s youth by:

  • improving the nutritional value of the foods being served and consumed,
  • increasing opportunities for physical activity,
  • eliminating exposure to environmental tobacco smoke and,
  • increasing the number of schools that adopt coordinated approaches to healthy schools.

The coordinated school health model includes eight components found in most schools: health education; physical education; health services; nutrition services; counseling, psychological and social services; healthy school environment; health promotion for staff; and family and community involvement.

The key strategies known to positively affect a school’s climate are:

  • learning and adopting healthy behaviors,
  • achieving lifelong physical fitness,
  • encouraging healthful nutrition,
  • enhancing school health services,
  • creating positive learning environments,
  • supporting social and emotional well-being,
  • promoting faculty and staff wellness, and
  • connecting school, parents and community.29

To address the needs of populations at highest risk, all partners and stakeholders must collaborate to identify high need schools. All ensuing programs will be sensitive to the cultural make-up of youth and staff by using materials in appropriate reading levels and languages.

While the Youth/Schools sector of the State cardiovascular health Plan focuses primarily on school-aged children, the plan will support and complement New York’s Eat Well Play Hard initiative, a public health intervention whose focus is to prevent overweight and chronic disease in pre-school children.

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Objective 1:

Increase the number of schools and youth programs that promote the lifelong behaviors necessary to reduce CVD by providing nutrition education, establishing an environment that encourages the purchase of healthy foods, and modeling good food choices by promoting healthy foods for meals and snacks.

Potential Action Steps:

  • Use the School Health Index results (when they become available in 2004) for development of baseline data and choosing target areas for initiatives.
  • Identify key people and agencies involved in funding policies, explore barriers and consider options necessary to promote healthy foods in schools. Enhance best practices that currently exist.
  • Develop food service policies in schools and youth-based programs to include:
    • Continued enforcement and increased compliance with the competitive food laws in all schools; these relate to any foods sold at school that are not part of a reimbursable school breakfast or lunch;
    • Research on the feasibility of adopting additional statewide standards for the sale of competitive foods that address nutrient content, portion size, availability, and age appropriateness (elementary vs. secondary);
    • Posting nutrition content of foods sold at their point of purchase;
    • Promoting the consumption of healthy breakfast, lunch, and snacks at schools, youth-based programs, staff meetings and events (concerts, sports, etc.);
    • Promoting provision of adequate facilities and time to eat, and involvement of youth in menu planning;
    • Encouraging creation of district-wide policies about vending machines in schools including making machines unavailable during mealtimes; developing vendor education programs designed for suppliers and establishing criteria for which food items are stocked in the machines; limiting serving sizes of soda to 12 ounces or less, if schools insist on selling soda; ensuring that criteria are followed through periodic evaluations;
    • Placing milk vending machines promoting low-fat and fat-free milk in all schools and ensure that the product is appealing (e.g., avoid cartons with missing kids on panels, ensure milk is cold). Include 100% juices and water for children who are lactose intolerant.
    • Promoting the healthy choice of produce grown in New York State;
    • Educating school administrators and other key decision makers about the connection between health and learning and the benefits of reflecting the messages taught in health and nutrition courses in the food served; and,
    • Working with individuals with a special interest in school health:
      • Incorporating a holistic approach to nutrition education through health education, physical education, family and consumer science courses and community education;
      • Providing sample heart healthy menus that can be incorporated into curriculum where meal planning and preparation are taught;
      • Teaching about foods and where they come from, label reading and the national food guide;
      • Teaching cooking; and
      • Teaching children how television viewing can adversely affect their health as a sedentary behavior promoting poor eating habits through advertisements of low nutrient dense foods.

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Objective 2:

Encourage increased levels of moderate physical activity for all youth by increasing both the accessibility of facilities where they can engage in physical activity and increasing the availability of physical activity programs that promote lifelong activity.

Potential Action Steps:

  • Use the School Health Index results (when they become available in 2004) for development of baseline data and choosing target areas for initiatives.
  • Promote daily physical activity for all grades K-12, emphasizing the importance of regular physical activity for lifelong health by:
    • Encouraging elementary schools to adopt recess periods and allow children to engage in active play;
    • Supporting the NYS Education Department in its efforts to increase the proportion of schools that comply with elementary physical education regulations;30
    • Increasing physical activity in after-school programs;
    • Supporting limits on use of television, videos and non-educational computer use;
    • Training physical education teachers to instruct students in lifetime activities; and,
    • Developing policies regarding denying recess or other activity opportunities.
  • Promote better use of public facilities for physical activity opportunities by:
    • Encouraging schools to open their facilities (gyms, swimming pools, and hallways) for before- and after-hour use by community residents and after-school programs and promoting after hours activities at schools (yoga, ballroom dancing, etc.) for community members and older students;
    • Creating safe community playground facilities;
    • Providing covered, lighted and accessible bike racks at schools and after-school/community program locations;
    • Providing opportunities for hall and campus walking for students, staff and community members;
    • Distributing information about the development of facilities for inline skating, skateboarding, BMX biking and other activities;
    • Providing information to municipalities on liability through municipal insurance providers, to encourage development of recreational facilities; and,
    • Involving youth in planning physical activities that will engage and increase the level of physical activity of their peers.
  • Promote comprehensive Walk Our Children to School and Safe Routes to School initiatives by:
    • Encouraging use of the Walkability Checklist and developing projects to address problems identified;
    • Encouraging street monitors to increase safety for children walking to school;
    • Assessing barriers and identifying strategies to encourage daily walking to school; and,
    • Reporting information gathered from Walk Our Children to School events to appropriate city officials, creating a website to enroll schools, encouraging college students to promote project activities, and encouraging schools to use Walk Our Children to School Day to launch Safe Routes to School Initiatives to work with communities on bike and pedestrian safety.
  • Encourage school-community collaboration by:
    • Promoting community service projects that involve physical activity (e.g. Crop Walk, Habitat for Humanity, walking neighbor’s pet, raking leaves);
    • Promoting physical activity for all populations, including a variety of fun or entertaining pastimes or activities;
    • Promoting enjoyable and lifetime activities at schools;
    • Involving youth in planning; and,
    • Providing opportunities for parents, guardians and youth to engage in physical activity programs together; create a website to promote, educate and motivate students and parents to take part in physical activity, record dietary habits and provide behavioral cues to action.

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Objective 3:

Increase the number of elementary and secondary educational institutions that implement effective tobacco-free policies to eliminate tobacco use from all facilities, property, vehicles and events.

Baseline: 15% of NYS youth reported using tobacco products on school property in past 30 days (1999)31.

Target Indicator: Decrease by 10% the number of NYS youth who report using tobacco products on school property.

Potential Action Steps:

  • Promote New York State Clean Indoor Air Act (Article 13E PHL) on school grounds and at school-sponsored events by:
    • Assisting county health officials and school administrators to coordinate enforcement efforts in their local communities;
    • Developing mechanisms to report complaints and violations of the Clean Indoor Air Act in schools.
  • Address the needs of specific risk groups by identifying partners with data or information about disparate populations within the state including African Americans, Hispanics and low-income populations.
  • Ensure that trainings are culturally sensitive and materials are developed in appropriate languages and reading levels.
  • Implement CDC’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction (1994), with special emphasis on policy, cessation for students, faculty, and family involvement and evaluation by:
    • Encouraging development and enactment of effective tobacco-free school policies;
    • Providing signage to support effective tobacco-free policies in the schools; and,
    • Educating the public about the law and the benefits of tobacco-free environments at school-sponsored events.

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Objective 4:

Increase the number of schools that have adopted a coordinated approach to school health by using the eight components of the coordinated school health model: health education, physical education and activity, health services, nutrition services, counseling and social services, school environment, parent/family/community involvement and staff wellness.

Baseline: 49% of schools report that they have a health advisory council in place.32

Target Indicators: Increase by 10% the number of schools reporting health advisory councils.

Potential Action Steps:

  • Promote use of CDC’s School Health Index, with particular emphasis on the policy section by:
    • Distributing the Physical Activity and Nutrition “Ready, Set, Go” toolkit developed by the Statewide Center for Healthy Schools;
    • Integrating state and local involvement in training school staff about physical activity and nutrition issues;
    • Targeting schools with health centers to implement the School Health Index;
    • Assisting schools with on-line reporting of the results from the School Health Index;
    • Identifying partners to promote use of CDC’s School Health Index;
    • Seeking guidance from associations of professionals in business and government to lead program actions; and,
    • Supporting programs in low-income areas.
  • Develop policies that create school environments supportive of behaviors and choices consistent with health messages and goals related to each of the eight components of the coordinated model. Provide technical assistance to schools in policy development.
  • Establish the “essential components” of a coordinated school health approach by:
    • Working toward school-community health councils in every school district;
    • Developing school-based teams at individual schools that incorporate nutrition, physical activity and tobacco control programs; and,
    • Training well-prepared district health coordinators.
  • Promote screening and appropriate treatment for CVD risk factors in school-based health centers.
  • Collect height and weight data in a representative sample of 3rd grade children.

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Health Care Sector

The health care delivery system in New York State continues to play a crucial role to play in the prevention and management of the cardiovascular and cerebrovascular disease of its residents. Physicians, physician extenders, nurses, pharmacists, nutritionists, physical therapists and other health care workers can all influence the health behaviors of their patients to prevent or better manage risk factors for heart disease and stroke.

Research has shown a significant disparity between the scientifically supported standards of prevention and treatment and the type of care offered to patients in many clinical settings. Public health officials and health care providers can continue to promote quality care, consistently provided to all patients, by advocating for adherence to evidence-based clinical guidelines and providing the necessary support and training to health professionals throughout the state. This will have the best chance of success if partnerships are formed among organizations of influence, including hospitals, physicians groups, insurers, and professional and voluntary associations.

Risk prevention refers to the activities of health professionals to prevent individuals from developing risk factors for heart disease, stroke or other CVDs. These risks include: unhealthy eating, lack of physical activity, tobacco use, hypertension, hyperlipidemia, diabetes, overweight and obesity. Physicians and other health professionals can continue to counsel their patients about these risks. Risk management refers to the activities of health professionals to treat and reduce identified risks, to prevent disease progression or complications.

For individuals with diagnosed risk factors, the focus should be on secondary prevention. The major goal of secondary prevention is to reduce cardiovascular disease complications, recurrent cardiac events and further progression of underlying disease through both medical intervention and alteration in an individual’s lifestyle and health habits. Risk factor modification is the cornerstone of activity through which secondary prevention is accomplished. Leading organizations such as the American Heart Association and the American College of Cardiology have long recognized the importance of risk factor modification and have developed evidence-based guidelines for both risk factor prevention and risk factor modification. These guidelines have tremendous potential to reduce the cardiovascular disease event rate among those with known disease.33

Individuals with hypertension, for instance, should be treated with therapeutic lifestyle change and/or medications to normalize blood pressure. High blood cholesterol should be similarly treated. The management for patients with diabetes is especially crucial; normal weight, blood pressure and cholesterol levels must be achieved and maintained in these individuals in order to reduce their risk of stroke or heart disease.

Disease management efforts have been shown to be more effective when conducted by interdisciplinary teams.34 Such teams may include physicians, nurses, health educators, dietitians, psychologists or rehabilitation therapists. Teams were shown to “improve processes of care, reduce admissions to hospital, and enhance quality of life or functional status in patients with coronary heart disease.” Nurse-led clinics are another proven method to provide secondary prevention to patients with cardiovascular disease. In one trial, subsequent cardiac events were reduced by almost one-third in such a clinic.35Under the direction of physicians, nurses in these clinics counsel patients regarding treatment adherence as well as health behaviors. Stroke teams within emergency departments have also been shown to be effective. According to one study, “the highest priority for providers of a stroke service must be to establish a stroke unit and multidisciplinary team that delivers organised stroke care.”36

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Objective 5:

Increase the awareness of and adherence to evidence-based clinical guidelines promoting: 1.) risk prevention, 2.) risk management, and 3.) clinical treatment of diagnosed cardiovascular and cerebrovascular disease using effective systems of delivering health care and clinical protocols.

Potential Action Steps:

  • Investigate methods of determining baseline data for this objective.
  • Consider the feasibility of a pilot study to assemble data on costs of programs aimed at increasing adherence with clinical protocols.
  • Encourage the use of systems and protocols within health care settings to provide:
    • Effective means to internally monitor adherence and outcomes related to the use of guidelines within medical practices, insurers or hospital sites;
    • Access to current individual patient data useful in treating patients, especially in the acute setting (in compliance with all State and Federal privacy regulations);
    • Improved office, emergency room and hospital efficiency through rapid dissemination of accurate and appropriate patient care information;
    • Avoidance of duplication of tests, of lost or misplaced medical records, and elimination of unnecessary duplication of prescriptions to avoid adverse drug-drug interactions before they occur; and,
    • Reduced waiting times for patients in all health care settings.
  • Identify reimbursement structures that address health education, risk prevention and risk management of CVD.
  • Encourage organized systems of patient friendly and culturally competent follow-up to ensure that patients get to needed aftercare, understand instructions, and to assist patients with difficulties implementing follow-up recommendations.
  • Encourage the Medicaid and Medicare programs, and other payers, to ensure that evidence-based guidelines for prevention and management of CVD are followed.
  • Increase professional education in medical, nursing and pharmacy schools about risk factor prevention, risk factor management and treatment of CVD.
  • Encourage community health centers and other ambulatory care settings serving low-income populations to develop quality improvement programs using evidence-based guidelines.
  • Encourage physicians’ groups to screen for obesity and provide appropriate counseling.

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Objective 6:

Increase the availability and expertise of “health care teams” in settings across New York State to provide risk prevention or risk management care for all age groups, focusing on stroke teams and heart attack teams for emergent cases.

Potential Action Steps:

  • Investigate methods of determining baseline data for this objective.
  • Provide health professionals and administrators with evidence that this approach improves outcomes while reducing costs.
  • Connect health care organizations seeking to implement a team approach with organizations with similar teams for hands-on training experiences and as potential resources for professional and patient education materials and tools.

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Objective 7:

Increase the understanding of the burden of cardiovascular and cerebrovascular disease in New York State, particularly with regard to the special needs of women and underserved populations.

Potential Action Steps:

  • Promote research to better understand the reasons for demographic disparities in the State related to the prevalence of CVD.
  • Evaluate current CVD data, and develop a mechanism to bring stakeholders together to:
    • Improve our understanding of existing CVD data and identify gaps in information;
    • Network with a wide variety of state, national and academic epidemiologists, researchers and others involved in CVD prevention, treatment, surveillance, evaluation and research;
    • Promote ways to reduce the evidence/practice gap surrounding cardiovascular care within NYS;
    • Better assess high-risk populations and communities;
    • Identify underserved populations such as women and minorities; and,
    • Based on data, develop initiatives, programs and health education projects.
  • Research the feasibility of developing an accessible, coordinated database to collect, store and disseminate accurate morbidity and mortality data. Potential applications include monitoring health care systems providing cardiac care, improving treatment outcomes, enhancing primary and secondary prevention measures, and targeting site-specific and audience-specific high risk population interventions. The following sub-components should be included in the analysis:
    • AMI-Acute myocardial infarction, as proposed and supported by the Cardiac Advisory Committee of NYS;
    • CVA-Stroke, after learning the results of the pilot study of the Paul Coverdale Stroke Registries in four states;
    • CHF-Congestive Heart Failure; and,
    • PAD-Peripheral Arterial Disease.
  • Investigate the concept of a Center(s) of Excellence for Cardiovascular Disease Prevention and Research within NYS, to coordinate the efforts of the Department of Health, cardiologists, academicians, and others working in the field of cardiovascular and cerebrovascular risk prevention and management.
  • Increase awareness of the economic burden of cardiovascular disease.
  • Continue the work of the Access Subcommittee of the Cardiac Advisory Committee.
  • Assist with implementing recommendations developed by the New York State Department of Health’s Quality Initiatives Workgroup on access to specialty care.
  • Encourage community health centers to join in collaborative efforts to improve the quality of care to all CVD patients.
  • Improve the knowledge base of CVD burden in special populations by:
    • Identifying partners with data or information specific to CVD risk, prevention and treatment in women within the State;
    • Identifying “Best Practice” models of care that address the uniqueness of CVD in women;
    • Encouraging mechanisms to dispel the myth that women do not need to worry about heart disease and increase women’s and their providers’ awareness of risk of heart disease and stroke;
    • Identifying partners with data or information about disparate populations within the State including African Americans, Hispanics, and low-income populations; and,
    • Encouraging local community health center programs that offer a wide variety of culturally sensitive, educational interventions across the State to increase the awareness of CVD in high-risk populations.

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Objective 8:

Increase the number of New Yorkers who receive fast, appropriate emergency care for a cardiac event or a stroke.

Potential Action Steps:

  • Promote Brain Attack Coalition (BAC) recommendations for quality stroke systems.
    • Support training sessions on BAC recommendations.
    • Promote policy and system change to assure stroke is treated as an emergency by emergency medical services (EMS) and hospitals.
    • Promote policy and system change to assure hospitals follow guidelines to improve quality of care for stroke patients.
  • In worksites, assure employee awareness of signs and symptoms of heart attack and stroke, the need to call 9-1-1, and use of automatic external defibrillators (AEDs) and cardiopulmonary resuscitation (CPR).
    • Use existing communication resources such as those from American Heart Association and the National Heart, Lung and Blood Institute.
    • Collaborate with worksite wellness coalitions.
    • Utilize electronic venues (e.g., email) to educate about signs and symptoms.
  • Provide public awareness on use of 9-1-1, emergency departments’ services, signs and symptoms of heart attack and stroke.
  • Promote universal, enhanced 9-1-1 coverage.
    • Assist EMS providers and other key partners in communicating the need for enhanced service.
  • Promote the placement of AEDs.
    • Promote availability in rural communities and the need for policies and training to assure appropriate use.
  • Promote strong emergency medical systems for heart attack and stroke.
    • Support emergency medical dispatcher training on stroke signs and symptoms, recognition of a 9-1-1 emergency call, pre-hospital acute stroke assessment, and priority dispatching to hospitals that can comply with stroke treatment guidelines.
  • In schools, raise awareness in classrooms and with groups like Parent-Teacher Associations of signs and symptoms of heart attack and stroke and the importance of calling 9-1-1.

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Worksite Sector

Since most adults spend more than half of their waking hours working, worksites are good settings to promote heart health. Worksites are environments with both definite physical boundaries and defined target populations to implement environmental and policy changes.

Health promotion and primary and secondary prevention can occur through wellness programs including worksite-based weight reduction, smoking cessation, and blood pressure screening and by making adjustments at the worksite to provide flexible work time for walking breaks, access to healthy foods such as fruits and vegetables, low-fat items in vending machines, smoke-free policies, and safe and appealing stairwells.

Research shows that offering alternative work schedules reduces stress, decreases absenteeism, improves productivity and allows workers to better manage their work and personal lives. As a result, workers have more time to shop for and prepare healthy foods for themselves and their families and have time for physical activity.

Employers pay a large proportion of health care costs through employee and dependent health benefits, costs related to employee illness and injury, absenteeism, and loss of productivity. Reducing behavioral risk factors through worksite health promotion and prevention will reduce chronic diseases and their subsequent costs, as well as improve the quality of life for employees.

In order to make worksite programs successful, senior level staff must demonstrate a commitment to provide work settings conducive to healthy behaviors. This can be achieved by including wellness in mission statements, encouraging development of employee wellness programs, and by senior staff participating actively in those programs.

There are three basic approaches to worksite wellness: identification and treatment of high-risk individuals, environmental and policy changes to increase supports for healthy behavior, and changes to the health benefit structure (e.g., reducing health insurance rates for non-smokers). The first two have existed for many years while the third is newly emerging. The first two approaches, used in combination, have an additive affect. Common among the approaches is the length of time for a return on investment. It takes at least one year and often two or three to realize a return on investment, with the literature reporting a range of 1.4:1 to 6:1.37 The return is greatest for the most intensive approach: identifying high-risk individuals and providing appropriate treatment. This includes providing individual counseling and changing the environment to support healthy behaviors. The data are sparse on the environmental and policy approach alone. Most studies did not look at these changes independent of other worksites wellness initiatives. The NYS Healthy Heart Program is currently evaluating its efforts in the environmental and policy change approach in worksites. Through worksite and individual behavior surveys, data have been collected to examine the relationship between individual health behaviors and worksite supports for heart health. While data on the return of investment from health benefit structure changes are sparse, some data suggest that employees who are reimbursed some or all of a fee for participating in a health improvement program are more likely to practice the targeted healthy behaviors.

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Objective 9:

Increase the level of worksite supports (policies, practices and facilities) to promote active lifestyles.

Baseline data38:

  • 9% of worksites have written policies to support exercise or physical activity.
  • 18% provide exercise or fitness facilities.
  • 25% offer discounted or subsidized membership to health clubs or gyms.
  • 20% offer physical activity-oriented programs.
  • 49% have safe places for recreational walking at the worksites.

Target indicators: Increase all by 10%.

Potential Action Steps:

  • Provide worksites with model policies that support physical activity during work time or support employee health through physical activity in mission statements.
  • Identify ‘best practices‘ worksite physical activity interventions.
  • Provide opportunities for human resources personnel to learn about the benefits of health promotion.
  • Develop advice for employers negotiating with health insurance providers for discounted health insurance, increased life insurance, or other incentives for employees who maintain certain levels of physical activity.
  • Develop local partnerships to provide incentives, such as discounts towards the purchase of a bicycle or walking shoes, for employees who routinely walk or bike to work.
  • Advocate for development of worksite policies regarding safe, well-lighted and maintained stairwells to encourage stair walking.
  • Establish a network of available, on-site physical activity group facilitators for use by employers through support of the NYS Physical Activity Coalition, NYS Association of Health, Physical Education, Recreation and Dance, the American College of Sports Medicine and other partners. Consider students from local colleges or universities as group activity facilitators.
  • Offer technical assistance, provided by the New York State Physical Activity Coalition and other partners, for worksites to implement the Move For Life Campaign, including ongoing collection of data on employee participation.
  • Recognize worksites that implement heart healthy policies, practices and facilities, such as flexible work schedules, healthful foods at meetings and outdoor exercise areas with a certificate from the New York State Department of Health.
  • Establish recommendations for new worksite construction or renovation to include showers, changing areas and access to opportunities for walking.
  • Work with community-based organizations to promote events entailing physical activity such as the American Diabetes Association Tour for the Cure, American Cancer Society Relay for Life, or the American Heart Association Heart Walk.
  • Establish working relationships with umbrella organizations (merchants associations, Chambers of Commerce, Business Improvement Districts, Business alliances) to support activities directed towards small businesses (less than 100 people).
  • Address the needs of high-risk populations by assisting organizations targeting more than 50% of their activities to worksites with disparate populations. Target worksites with a majority of employees from minority populations or low-income employees, or workers with disabilities. Promote activities in all worksite sizes (a majority of the disparate population work in sites with less than 50 employees).

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Objective 10:

Increase the level of worksite-based resources (policies, practices and facilities) that support heart healthy eating.

Baseline:

  • 14% of worksites have a policy to make healthy food options available to the employees.
  • 16% provide labels to identify healthier food choices.
  • 25% provide low-fat milk, water, low-fat snacks or fresh fruit through vending machines or the cafeteria.

Target indicators: Increase all by 10%.

Potential Action Steps:

  • Provide employers with model policies for the provision of healthy options at company-sponsored meetings and functions.
  • Define and publicize criteria for healthful food and healthful food options at meetings and employee gatherings.
  • Encourage worksites to adopt specific nutrition interventions including:
    • Promote fresh produce coupon campaign by establishing a working relationship with supermarket corporate office consumer service representatives;
    • Encourage placement of low-fat milk, water and 100% juice vending machines at worksite locations;
    • Establish quantity discounts with vendors for high sales volume of health items;
    • Encourage employers to purchase microwaves, refrigerators and toaster ovens at worksites of all sizes, to allow workers to prepare healthy lunches on-site; and
    • Encourage worksites to partner with local Cornell Cooperative Extension offices and offer incentives to employees who attend on-site nutrition education programs provided by qualified nutrition professionals.
  • Provide advice to employers negotiating with managed care organizations for reduced health plan rates for employees who engage in weight management, diabetes care and medical nutrition therapy.
  • Develop model health vending contracts and lists of acceptable healthy foods. Distribute this information through multiple channels such as the NYS Business Council, the NYS Healthy Heart Worksite Initiative, the NYS Association of County Health Officials and others. (Target: 50% of items in vending machines are heart healthy)
  • Provide training in healthy eating and cooking to school food service managers, restaurants, employees and food preparers.
  • Encourage provision of healthy eating prompts to employees using paycheck stuffers, posters, signs and emails. Prepare and distribute a manual of tips to employers.
  • Encourage use of NYS-produced food as much as possible by supporting the NYS Farm to School Program, a partnership with the New York State Department of Health Division of Nutrition.
  • Provide worksites with materials to negotiate corporate rates for worksite-based weight control programs.
  • Encourage development of working relationships or partnerships with local greenmarkets and farmers markets to offer coupons and promotions.

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Objective 11:

All worksites are required to be tobacco-free.39 One hundred percent will have written policies about tobacco use and ban smoking within buildings and prohibit the sale of tobacco (excluding sites that sell to the public, e.g., supermarkets).

Baselines:

  • 87% have written policies about smoking and tobacco use.
  • 82% ban smoking within worksite buildings.
  • 91% prohibit the sale of tobacco to employees on the premises.

Target indicators: Increase all by 10%.

Potential Action Steps:

  • Establish partnerships between employers and organizations involved in worksite wellness with the local New York State Tobacco Control Coalitions.
  • Target groups with high smoking rates, such as White women between the ages of 18 and 24, and pregnant women, and encourage development of programs that are sensitive to the cultural makeup of worksites using materials in appropriate languages and reading levels.
  • Distribute model policies for smoke-free worksites, prohibiting smoking in company owned vehicles and prohibiting sales of tobacco products on site (e.g., no cigarette vending machines). Identify “best practices” in worksite-based and worksite-linked smoking cessation and encourage companies to offer smoking cessation programs at no cost to employees on-site during work hours.
  • Provide advice to employers on negotiating reduced health plan rates for non-smokers, and coverage of pharmaco-therapeutics and counseling for smoking cessation.
  • Support the establishment and enforcement of policies prohibiting smoking nearby worksite entrances.

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Objective 12:

Increase the percentage of worksites that offer preventive health screenings to employees in a 12-month period.

Baseline:

  • 17% of worksites provide a health risk appraisal, which is a general assessment of health.
  • 33% provide any kind of health screening.
  • 86% provide blood pressure screening.
  • 46% provide cholesterol screening.

Target indicators: Increase all by 10%.

Potential Action Steps:

  • Target worksites in which a majority of employees do not have health insurance or are otherwise known to be at risk of low screening rates.
  • Ask local ethnic clubs, faith-based organizations and others to encourage their communities to participate in screenings offered at their worksites.
  • Offer employees information on recommended screenings by age and gender in a non-threatening way.
  • Assure that screenings are offered in a manner sensitive to the cultural compositions of the worksites. Use materials in appropriate languages at appropriate reading levels.
  • Encourage worksites and health plans to offer annual screenings for hypertension, blood lipids and diabetes that are free, on-site, to all employees as part of the employees’ health benefit plan with confidential sharing of results with the primary care physician and appropriate follow up.
  • Promote health care coverage for employees and their families that includes primary and secondary prevention services addressing heart disease and stroke and rehabilitation services for heart attack and stroke survivors.
  • Encourage employers to work closely with health plans to provide appropriate treatment of employees with hypertension, hyperlipidemia, diabetes and other risk factors for cardiovascular disease.
  • Assist worksites to provide opportunities for employees to monitor their blood pressure on-site through occupational health nurses, self-monitoring machines or other means.
  • Partner with the NYS Business Council, New York State Association of Chambers of Commerce and others to provide employers with information about NYS insurance for small businesses, to facilitate enrollment and coverage of screenings and other health services.

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Objective 13:

Increase the percentage of worksites that offer alternative or flexible work schedules to make it easier for individuals and families to be physically active.

Potential Action Steps:

  • Investigate methods of determining baseline data for this objective.
  • Provide employers with model policies offering flexible scheduling to employees to assist workers in finding time for physical activity. Provide information on the cost and benefits of those policies.
  • Publicize existing materials which can assist employers and employees with Alternative Work Schedule implementation.
  • Encourage research and development of additional guidelines, as needed, to contribute to successful experiences with alternative work schedules.

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Community Sector

Additional environmental and policy changes are needed to increase levels of physical activity and to improve food choices throughout communities. Current research shows two important findings. First, walking is by far the most common form of leisure time physical activity among New Yorkers and second, communities play critical roles in promoting or hindering the adoption of healthy physical activity and eating habits by their members. For example, inventions such as creating accessible trails are associated with increased levels of physical activity among neighboring residents.

The Task Force on Community Preventive Services recently issued research-based recommendations on interventions that are likely to increase physical activity. Recommended interventions include:

  • Community-wide campaigns to encourage physical activity through multiple media channels combined with media events and physical activity opportunities;
  • Enhanced access to places for physical activity; and,
  • Social support interventions in community settings to build social networks around physical activity, such as walking clubs or “buddy” systems.

Physical environments along with social environments that support walking and other types of activity are essential to increase the prevalence of physical activity. These include such measures as building safe and accessible places to walk and bicycle both for recreation and for transportation; locating schools and other public facilities within walking distance of the neighborhoods being served; having safe and accessible parks and playgrounds for all ages; and opening community resources (such as schools, public buildings and shopping malls) to the public for physical activity.

Also critical to heart health is changing the way people eat. Studies show, during the past 20 years, portion sizes of food have become significantly larger, especially in meals eaten away from home. When people are served more food, they eat more food. For individuals to choose healthy diets, they must have healthy food choices available in their communities. This can range from encouraging grocery stores to offer healthy choices in inner-city neighborhoods and expanding farmer’s markets, to encouraging a wider availability of low-fat milk in vending machines and fast food outlets.

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Objective 14:

Increase the proportion of New Yorkers who report that it is safe, accessible and comfortable for them to walk or bike near their homes or worksites.

Potential Action Steps:

  • Investigate methods of determining baseline data for this objective.
  • Promote the concepts and importance of walking and walkable communities to local officials (elected officials, planning board members, and local transportation and land use professionals, etc.) in order to encourage changes in practices, ordinances, policies and zoning regulations.
  • Investigate how to best implement the concepts of walking and walkable communities in inner-city neighborhoods.
  • Conduct research to learn what messages and strategies, particularly with regard to personal safety, will promote walking.
  • Conduct research to learn how to change the attitudes and practices of local officials and develop information for local officials, based on the findings.
  • Develop packages of materials to market the concepts to different disciplines, based on results of research.
  • Investigate developing model local level policies, ordinances and zoning regulations that support the concepts of walkable communities.
  • Explore working with the Department of State and others to develop and distribute a guide to the tools available to local officials for creating more walkable environments.
  • Explore changing current State Education Department recommendations to favor building new schools closer to residential areas.
  • Explore incentives to municipalities and developers to create communities that support health.
  • Support existing community-based organizations and faith organizations that already work in inner-city neighborhoods to promote walking and walkable communities.
  • Support local Safe Routes to School projects to promote walking and bicycling to school and to make conditions safer for engaging in these activities by:
    • Expanding promotion of Walk to School Day/Week;
    • Encouraging local projects to highlight the need for infrastructure and enforcement improvements that will make it safer for children to walk or bike to school;
    • Involving local law enforcement and other walking groups;
    • Collaborating with senior citizen groups to escort children to school; and,
    • Assisting the Department of Transportation in conducting traffic-calming training for local transportation professionals and improving conditions to make it safer for children (and staff) to walk and bike to school.
  • Assist local pedestrian support groups to work effectively with local transportation and land use decision makers to make it easier and safer for people to walk by:
    • Developing a directory of existing local pedestrian support/advisory groups and establish mechanisms for networking;
    • Providing regional training for local pedestrian support groups use; and,
    • Foster connections between citizen support groups and local government officials, using Pedestrian Road Shows, educational materials and other means.
  • Engage law enforcement in efforts to increase interaction with the public regarding pedestrian and vehicle traffic laws by:
    • Involving local law enforcement officials in supporting walking initiatives, such as walking groups or Walking to School projects;
    • Supporting Safe Routes to School initiatives in inner-city neighborhoods; and,

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Objective 15:

Increase the percentage of New Yorkers who walk or bike regularly for leisure and for transportation.

Baseline: 8% of NY adults walked at least 5 days a week for at least 30 minutes a day.40

Target Indicator: Increase by 20%.

Potential Action Steps:

  • Consider the feasibility of conducting a campaign aimed at increasing moderate levels of physical activity by:
    • Assessing people’s understanding of the current recommendations for moderate activity, particularly the option to accumulate activity over several short periods of time during the day;
    • Conducting research on how to encourage New Yorkers to walk and bicycle when taking short trips, with a specific component targeted toward low-income, minority, inner city residents and people with disabilities, to determine how to best motivate them to incorporate more physical activity into their daily lives; and,
    • Conducting walking promotions, evaluating results and, if successful, replicating in other parts of the state.
  • Promote the use of New York State parks as a means of increasing physical activity for individuals and families.

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Objective 16:

Increase the percentage of food service establishments that offer appropriate portion sizes and healthful food choices.

Potential Action Steps:

  • Investigate methods of determining baseline data for this objective.
  • Educate consumers about appropriate portion sizes and motivate them to make specific behavioral changes to reduce portion sizes, particularly of food eaten away from home by:
    • Exploring efforts in other states to educate consumers about portion sizes;
    • Reviewing research on portion sizes and conducting additional research as needed to learn how different target audiences perceive the issue and ways to influence their behavior; and,
    • Developing, implementing and evaluating interventions to reduce portion sizes people consume.
  • Work with restaurants and other food outlets to encourage the availability and promotion of smaller portion sizes by:
    • Supporting national, state and local efforts supporting calorie and fat labeling on foods served by chain restaurants;
    • Exploring the possibility of working with regional offices of chain food service companies to support smaller portion sizes;
    • Exploring ways to promote components of the Just Ask Us campaign that encourages customers to request that a portion of their meal be set aside in a take home container before the meal is served; and,
    • Working with culinary training programs to train future food service professionals on the importance of reducing portion size.
  • Develop methods of collecting data to monitor the portion sizes commonly consumed of foods that contribute significantly to excess caloric intake.

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Objective 17:

Increase the availability of reasonably priced, healthful food choices in low-income neighborhoods.

Potential Action Steps:

  • Review and collect data as necessary on the availability of healthful food choices in selected inner city neighborhoods.
  • Gather information on successful models for locating groceries in inner-city neighborhoods.
  • Explore innovative ideas for increasing access to healthful foods such as neighborhood co-ops, groceries run by not-for-profits, and vans to deliver fresh produce to neighborhoods, and others.
  • Assemble a broad array of interested partners to discuss the issue and develop pilot projects that could be carried out with funding from combined sources (e.g., economic and community development funds, United Way, etc.).
  • Increase farmer’s markets and direct marketing opportunities for local farmers in inner-city neighborhoods. Expand on current efforts to link consumers and farmers, (e.g. the US Department of Agriculture’s Farm to School Project, agricultural tourism, etc.)

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Objective 18:

Encourage consumption of milk for those able to drink milk and increase the proportion of milk drinkers who consume low-fat milk (1% or fat-free).

Potential Action Steps:

  • Investigate methods of determining baseline data for this objective.
  • Encourage placement of vending machines for low-fat milk in schools, government/public buildings, highway rest stops, etc.
  • Build partnerships with farmers to promote low-fat milk.
  • Build partnerships between state agencies, such as Health, Agriculture and Education to promote the consumption of low-fat milk and strengthen the economic vitality of New York’s farmers and farming communities.
  • Encourage the creation of new low-fat dairy products and packaging methods.
  • Work with food programs (WIC, Child and Adult Care Food Program, School Lunch, etc.) to implement policies supporting low-fat milk.

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Objective 19:

Increase the skills of health professionals in the areas of community, environmental and policy interventions related to physical activity and nutrition.

Potential Action Steps:

  • Investigate methods of determining baseline data for this objective.
  • Make presentations to professional groups about policy and environmental changes by:
    • Developing a presentation and interactive activity to present to professional organizations on environmental, policy and community approaches to physical activity and nutrition; and,
    • Developing model materials to present at conferences of health professionals to train health professionals to make presentations on the importance of walking and more walkable communities to different community groups and at public hearings.
  • Encourage recognition of specialists in environmental and policy approaches to physical activity and nutrition, and consider how to best promote their expertise.

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Appendix A: Resources

Resources are readily available to substantiate the rationale for the proposed actions along with guidance for implementation.

Tobacco

Resources to assist communities in developing effective tobacco control programs, emphasizing a comprehensive approach, are widely available on the Internet.

Physical Activity

The science base for the benefits of physical activity, as well as interventions that have been effective in promoting physical activity across the lifespan can be accessed at:

Nutrition

Recommendations for a heart healthy diet have been developed by the American Heart Association and the National Institutes of Health:

Cholesterol:

The evidence for reducing elevated cholesterol and what action should be taken are summarized in several key documents:

The National Cholesterol Education Program has issued clinical practice guidelines on the prevention and management of high cholesterol in adults:

The Guide for Clinical Preventive Services,Second Edition, has issued recommendations for Screening for High Blood Cholesterol and Other Lipid Abnormalities

Recommendations for blood cholesterol screening have been developed:

High-Risk Populations:

Resources for taking action to reduce disparities in cardiovascular health are available at:

Prevention Guidelines

American Heart Association and American College of Cardiology guidelines to assist health care professionals in preventing and treating cardiovascular diseases:

  • Primary: Pearson TA, et al: Circulation 2002; 106:388-391
  • Secondary: Smith, SC et al: Circulation 2001; 104: 1577-1579
  • Community: Pearson TA, et al: Circulation 2003; 107:645-651

Healthy People 2010

Healthy People 2010 is a set of health objectives for the nation to achieve over the first decade of the new century. It can be used by many different people, states, communities, professional organizations, and others to help them develop programs to improve health. Information and specific objectives related to cardiovascular disease can be found at:

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Appendix B: Workgroup Members

Association Name
American Heart Association, New York State Affiliate Susan Bishop
Mary Catherine Daniels
Darlene McEntee
Hospital Association of New York State (HANYS) Ray Sweeney
Catherine Ciccione
Medical Society of the State of New York (MSSNY) Pat Clancy
Mount Kisco Medical Group Abe Levy MD
New York Health Plan Association Arlene Halpert
New York State Association of County Health Officials (NYSACHO) Cristina Dyer-Drobneck
New York University Marion Nestle PhD, Workgroup Chair
NY City Department of Health Daria Luisi
NYS Association for Health, Physical Education, Recreation and Dance, Inc. Colleen Corsi – Gardner
NYS Association of Youth Bureaus Dennis McLaughlin
NYS Department of State/Division of Local Governments John Bartow
NYS Department of Transportation/Bicycle and Pedestrian Program Judith Kuba
NYS Education Department Jacquee Albers
NYS Public Health Association Bridget Walsh, Mary McCarthy
New York State Business Council Elliot Shaw
University of Rochester School of Medicine and Dentistry Thomas Pearson MD

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Footnotes

  1. US Department of Health and Human Services. A Public Health Action Plan to Prevent Heart Disease and Stroke. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention; 2003.
  2. American Heart Association, “Heart Disease and Stroke Statistics – A 2003 Update”, available at http://www.americanheart.org/downloadable/heart/10461207852142003HDSStatsBook.pdf
  3. American Heart Association, “Heart Disease and Stroke Statistics – A 2003 Update”, available at http://www.americanheart.org/downloadable/heart/10461207852142003HDSStatsBook.pdf
  4. Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System Online Prevalence Data, 1995-2002.
  5. American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas, Tex.: American Heart Association, 2001.
  6. The Burden Of Cardiovascular Disease In New York: Mortality, Prevalence, Risk Factors, Costs, And Selected Populations, New York State Department of Health, 2003.
  7. Department of Health and Human Services, Centers for Disease Control and Prevention, [Program Announcement 02045], Cardiovascular Health Programs
  8. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 270(18): 207-12.1993.
  9. American Heart Association website http://www.americanheart.org/presenter.jhtml?identifier=1200000
  10. Smoking and Health: A National Status Report. DHHS Publication No. (CDC) 87-8396. Centers for Disease Control (CDC), 1990.
  11. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 270(18): 207-12.1993.
  12. Hahn RA, Teuesch SM, Rothenberg RB, et. al. Excess deaths from nine chronic diseases in the United States, 1986. JAMA 264(20): 2554-59. 1998.
  13. Butler RN, Davis R, Lewis CB, et al. Physical fitness: benefits of exercising for the older patient. Geriatrics 53(10): 46-62. 1998.
  14. Bazzano LA, He J, Ogden LG, Loria CM, Whelton PK. Dietary fiber intake and reduced risk of coronary heart disease in US men and women: the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Arch Intern Med. 2003 Sep 8; 163 (16): 1897-904.
  15. Bazzano LA, He J, Ogden LG, Loria C, Vupputuri S, Myers L, Whelton PK.Legume consumption and risk of coronary heart disease in US men and women: NHANES I Epidemiologic Follow-up Study. Arch Intern Med. 2001 Nov 26; 161(21): 2573-8.
  16. Hyson, D. The Health Benefits of Fruits and Vegetables, A Scientific Overview for Health Professionals. Produce for Better Health Foundation, 2002.
  17. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, Maryland: Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, 1998.
  18. The Surgeon General’s Call To Action To Prevent Overweight and Obesity 2001. U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, D.C.
  19. Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2000 Summary. Advance Data. 2002; 328.
  20. Izzo JL Jr, Levy D, Black HR. Clinical Advisory Statement. Importance of systolic blood pressure in older Americans. Hypertension. 2000;35:1021-4.
  21. Chobanian, et. al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, The JNC 7 Report. JAMA. 2003; 289: (DOI 10.1001/jama.289.19.2560).
  22. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), NHLBI, available at http://www.nhlbi.nih.gov/health/dci/Diseases/hd/hd_risk.html
  23. American Diabetes Association, “Be Smart About Your Heart” 2002.
  24. 18,976,457; U.S. Census Bureau, 2000
  25. A statistical process applied to rates of disease, death and injuries or other health outcomes that allows different age structures to be compared.
  26. Kottke TE, Wu LA.Preventing heart disease and stroke: messages from the United States. Keio J Med. 2001 Dec; 50(4): 274-9.
  27. Cooper R. Cutler, J, Desvigne-Nickens, P. Fortmann, SP, Friedman, L. Havlik, R. Hogelin, G. Marler, J McGovern, P. Morosco, G. Mosca, L. Pearson, T. Stamler, J. Stryer, D. Thom, T. Trends and Disparities in Coronary Heart Disease, Stroke, and Other Cardiovascular Diseases in the United States. Findings of the National Conference on Cardiovascular Disease Prevention. Circulation. 2000; 102:3137.
  28. Heart Disease and Stroke Statistics: 2003 Update, American Heart Association. Available at http://www.americanheart.org/downloadable/heart/10461207852142003HDSStatsBook.pdf
  29. New York Statewide Center for Healthy Schools, 2001.
  30. Chapter 11 Regulations of the Commissioner, Subchapter G Part 135-Health, Physical Education and Recreation: (i) Elementary instruction program for grades K through 6. (a) all pupils in grades K-3 shall participate in the physical education program on a daily basis. All pupils in grades 4-6 shall participate in the physical education program not less than three times each week. The minimum time devoted to such programs shall be at least 120 minutes in each calendar week, exclusive of any time that may be required for dressing and showering; or (b) as provided in an equivalent program approved by the Commissioner of Education (ii) Secondary instruction programs-grades 7 through 12. All secondary pupils shall have the opportunity for regular physical education, but not less than three times per week in one semester and two times per week in the other semester.
  31. Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1999.
  32. Baseline data based on a survey conducted by the Statewide Center for Healthy Schools in which there was a 72% response rate or 512 of a possible 714 respondents.
  33. Wong, Nathan, Black, H. and Gardin, J. (2000). Preventive Cardiology. Brook, R. and Greenland, P. “Secondary Prevention,” Chapter 23. New York: McGraw-Hill, p. 557
  34. Finlay A. M., Lawson F., Teo K., Armstrong P. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001; 323: 957-962.
  35. Campbell NC, Ritchie LD, Thain J, Deans HG, Rawles JG, Squair JL. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart 1998; 80: 447-452
  36. Hankey, GJ and Warlow, CP. (1999). Treatment and Prevention of Stroke: evidence, costs, and effects on individuals and populations The Lancet 354. p. 1457-1463.
  37. Goetzel, R.Z., Juday, T.R, & Osminkowski, R.J. (1999) What’s the ROI: Presentation based on findings of article – A systematic review of return on investment (ROI) studies of corporate health and productivity management initiatives. AWHP’s Worksite Health, 12-21.
  38. All worksite baselines from DOH Healthy Heart Program, worksite health program, Heart Check results.
  39. Effective July 24, 2003, the amended New York State Clean Indoor Air Act (Public Health Law, Article 13-E) prohibits smoking in virtually all workplaces, including restaurants and bars.
  40. Behavioral Risk Factor Surveillance System (BRFSS)

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