Thomas A. Pearson|Latha Palaniappan|Nancy T. Artinian|Mercedes R. Carnethon|Michael H. Criqui|Stephen R. Daniels|Gregg C. Fonarow|Stephen P. Fortmann|Barry A. Franklin|James M. Galloway|David C. Goff|Gregory W. Heath|Ariel T.H. Frank|Penny M. Kris?Etherton|Darwin R. Labarthe|Joanne M. Murabito|Ralph L. Sacco|Comilla Sasson|Melanie B. Turner
American Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 Update
homecirculationvol 127 16american heart association guide improving cardiovascular health community level 2013 update free accessresearch articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessresearch articlepdfepubamerican heart association guide improving cardiovascular health community level 2013 updatea scientific statement public health practitioners healthcare providers health policy makers thomas pearson md phd faha cochair latha p palaniappan md ms faha cochair nancy artinian phd rn faha mercedes r carnethon phd faha michael h criqui md mph faha stephen r daniels md phd faha gregg c fonarow md phd faha stephen p fortmann md barry franklin phd faha james galloway md faha david c goffjr md phd faha gregory w heath dhsc mph faha ariel holland frank penny krisetherton phd rd darwin r labarthe md mph phd faha joanne murabito md scm ralph l sacco md ms faha comilla sasson md ms melanie b turner mphon behalf american heart association council epidemiology prevention thomas pearsonthomas pearson latha p palaniappanlatha p palaniappan nancy artiniannancy artinian mercedes r carnethonmercedes r carnethon michael h criquimichael h criqui stephen r danielsstephen r daniels gregg c fonarowgregg c fonarow stephen p fortmannstephen p fortmann barry franklinbarry franklin james gallowayjames galloway david c goffjrdavid c goffjr gregory w heathgregory w heath ariel holland frankariel holland frank penny krisethertonpenny krisetherton darwin r labarthedarwin r labarthe joanne murabitojoanne murabito ralph l saccoralph l sacco comilla sassoncomilla sasson melanie b turnermelanie b turner behalf american heart association council epidemiology prevention originally published21 mar 2013httpsdoiorg101161cir0b013e31828f8a94circulation 201312717301753other versions articleyou viewing recent version article previous versions january 1 2013 previous version 1 introductionthe goal american heart association guide improving cardiovascular health community level aha community guide provide comprehensive inventory evidencebased goals strategies recommendations cardiovascular disease cvd stroke prevention implemented community level guide advances 2003 aha community guide1 2005 aha statement guidance implementation2 incorporating new evidence community interventions gained past decade expanding target audience include broader range community advocates aligning concepts terminology aha 2020 impact goals recognizing contributions new public private sector programs involving community interventionsin recent years expanding arrays programs policies implemented increasingly diverse communities provide tools strategies best practices potentially reduce incidence initial recurrent cardiovascular events aha community guide complements aha statement entitled population approaches improve diet physical activity smoking habits3 supports aha 2020 goal4 improve cardiovascular health americans 20 reducing deaths cvds stroke 20 present aha community guide supports aha 2020 goal identifying exemplary regional national programs encourage cardiovascular health behaviors health factors formerly addressing risk behaviors risk factors communities might acquire proven strategies expertise technical assistance improving cardiovascular healththe aha community guide complements existing cvd community guidelinesthe aha community guide seeks prevent onset disease primary prevention maintain optimal cardiovascular health primordial prevention among broader segments population prior research indicates using public health strategies sodium reduction processed foods lower blood pressure58 tobacco laws promote smoking cessation911 modification built environment increase physical activity1214 preserve optimal levels cardiovascular health factors childhood throughout life course1516 shift entire distribution cardiovascular risk lower levels17 public health approach yields lifelong benefits terms good health reduced healthcare costs aha community guide complements existing aha national heart lung blood institute centers disease control prevention guidelines initiatives preserve cardiovascular health achieve primary secondary prevention heart disease stroke1830 existing policy statements guidelines heart disease stroke prevention target individuals healthcare providers centers disease control preventions guide community preventive services2728 addresses health behaviors comorbid conditions ie nutrition physical activity smoking obesity relevant cvd prevention however address comprehensive set cardiovascular health factors omitting example hypertension hypercholesterolemia thus despite existing cvd prevention guidelines individuals healthcare providers21222930 guide community preventive services31 comprehensive uptodate review community approaches cvd prevention important timely contribution comprehensive cvd prevention model united states rationale provides basis updated aha community guidethis guide unique opportunity build upon develop synergies advance multiple interventions policy changes occurring past decade affordable care act recent legislation federal policies set motion support enhance community engagement essential unique role prevention32 policies range implementation community assessment components hospitals development accountable care organizations well coverage preventive health services public private insurance integration community health workers many programs transformation communities policy infrastructure support cardiovascular health32identifying interventions populationwide cardiovascular health promotion cvd risk reductionvarious interventions populationwide health promotion risk reduction efforts categorized frieden33 health impact pyramid figure 1 base pyramid interventions broadest impact populations eg socioeconomic factors decreases bottom top top require greatest individual effort eg counseling education decreases top bottomdownload figuredownload powerpointfigure 1 health impact pyramid reproduced frieden33 permission publisher copyright 2010 american public health associationthe social environmental origins cvd long recognized mediated large part lifestyles behaviors modifiable cardiovascular health children predicts subsequent cardiometabolic health adulthood3435 affirming importance maintaining healthy lifestyle behaviors early life longitudinal population studies documented low lifetime risk heart disease stroke people risk factors153638 large reductions heart disease stroke mortality united states highincome countries since 1960s partially attributable populationwide reductions tobacco use dietary fat including saturated fat cholesterol3942 primordial prevention strategies allow maintenance optimal cardiovascular health longer period time larger portion population consistent aha 2020 goals4 considerable new evidence quantified relative costs interventions individual versus population level4344 according world health organization policy environmental changes may bring major reductions cvd burden countries less 1 per person per year whereas costs individual counseling drug surgical approaches least severalfold higher44the aha community guide recommends interventions targeted strata pyramid emphasis second level changing context make individuals default decisions healthy33 improvement socioeconomic status first level33 worthy goal society aha community guide fully recognizes critical importance social determinants cvd4546 aha community guide encourages communities implement communitywide interventions socially culturally appropriate47 reduce disparities inequities cardiovascular health socioeconomically disadvantaged subgroups4849the conceptual framework heart disease stroke prevention community levelpopulation approaches worldwide noncommunicable disease prevention come age past 20 years publication series declarations reviews international heart health society5051 international heart health society established policy framework experience base governmental agencies private sector nongovernmental organizations employers healthcare sector could join forces eliminating modern epidemic adopting new policies making regulatory changes implementing health promotion disease prevention programs directed entire populations50 agreement united nations recognizes noncommunicable diseases heart disease stroke constitute large part leading causes morbidity mortality healthcare cost worldwide52 documents consistently identify 3 dimensions figure 2 around communitywide approaches might organized optimal behaviors targeted populationwide change community setting targeted intervention public health interventions required populationwide changes improve cardiovascular health1 writing group members assigned task groups based optimal behavior intervention goal task groups responsible identifying evidence support behaviors cvd risk attributed populationwide recommendations maintenance cardiovascular health public health intervention goals recommendations improve cardiovascular health behaviors factors community current programs support strategic implementation intervention goals communitydownload figuredownload powerpointfigure 2 conceptual framework populationwide cardiovascular risk behaviors change optimal health behaviors factors community settings public health interventions modified pearson et al1 copyright 2003 american heart association inchealth behaviors factors targeted populationwide changethe list optimal behaviors deceptively brief table1 yet corresponds behaviors lack cvd risk attributed epidemiologic studies namely tobacco smoking exposure environmental tobacco smoke healthy dietary practices including healthy weight physically active lifestyle adherence healthcare recommendations hyperlipidemiahypertensiondiabetes mellitus assessment control early recognition treatment symptomatic coronary cerebrovascular disease including acute coronary syndromes transient ischemic attackstroke rationale inclusion list targeted behaviors includes high relative risk heart stroke associated individuals optimized behaviors factors3878 significant room improvement general us population specific communities79 evidence behaviors modifiable table 1 includes references systematic reviews previous aha scientific statements address first 2 criteria sources quantify risk prevalence targeted behaviors allowing burden heart disease stroke attributable estimated purposes promoting studies community level additionally table 1 identifies substantial shortfalls attaining healthy behaviors us populationtable 1 behaviors targeted improve cardiovascular health community level prevalence optimal levels us adult populationoptimal behaviorsprevalence us adults optimal behaviorsno tobacco reduce tobacco use5354 73 nonsmokers4 reduce exposure environmental tobacco smoke55healthy dietary practices1 meet 45 5 healthy dietary recommendations4 bmi 25 kgm2 appropriate caloric balance age sex height physical activity433 bmi 25 kgm24 increase vegetable fruit intake412 eat least 45 cupsd56 increase whole grain intake4577 eat least three 1oz servingsd56 increase fish intake45818 eat least two 35oz servingswk56 decrease fats4 saturated fat9 consume 7 saturated fat percent total calories56 trans fat dietary cholesterol5939 men 19 age consume 300 mgd6079 women 19 age consume 300 mgd60 decrease sugar461 decrease sugarsweetened beverages52 drink 450 kcalwk56 decrease salt6621 consume 1500 mgd56physically active lifestyle increase physical activity transport eg biking6365 occupationalworkrelated6365 increase active sports63 leisuretime physical activity planned exercise63666945 least 150 minwk moderate andor vigorous activity combined4adherence healthcare recommendations eg hyperlipidemiahypertensiondiabetes mellitus increase screening diagnosis risk factors bp total cholesterol fasting blood glucose1819 provide health care favorably modify behaviors risk factors597071 hypertension bp 14090 mmhg high total cholesterol 200 mgdl diabetes mellitus fasting blood glucose 126 mgdlbp42 untreated bp12080 mmhg4tc45 untreated tc200 mgdl4fbg 58 untreated fbg 100 mgdl434 us adults hypertension56of 80 aware hypertensionof 70 treatedof 46 control55 us adults high tc72of 50 aware high tcof aware high tc 54 treatedof high tc 33 control8 us adults diagnosed diabetes mellitustype 2 diabetes mellitus accounts 9095 diagnosed cases diabetes mellitus adults 5673of 73 aware condition56of 82 treated73of 57 control73early recognition treatment symptomatic disease encourage early presentation diagnosis treatment7476 improve emergency outofhospital care first responders747750 patients acute coronary syndrome obtain treatment within 15 h7425 patients acute stroke obtain treatment within 3 h74bmi indicates body mass index bp blood pressure fbg fasting blood glucose tc total cholesterol optimal refers levels associated lower risk developing cardiovascular diseasenational health nutrition examination survey nhanes 20052006nhanes 20052008nhanes 20032006atherosclerosis risk communities studypaul coverdell national acute stroke registrycommunity settings targeted interventionvarious community settings including worksites healthcare facilities religious organizations schools whole communities provide platforms programs promote improve health behaviors health factors comprehensive community intervention appears effective partners providing interventions multiple settings simultaneously80 interventions target entire communities mass media public policies necessary frequently used populationwide behavior change may sufficient reach underserved subgroups racialethnic minorities childrenyouth elderly subgroups additional targeted approaches often needed interventions programs improve lifestyle medication adherence promote early recognition symptomatic disease may especially effective healthcare settings worksites8182 rise social networking led new definitions virtual communities may targeted interventions finally many organizations located people live work worship study play may able provide especially effective programs using local media leaders policies influential grassroots levelin instances communitybased interventions failed fully consider receiving information setting educational programming occurs programming delivered approaches may actually promulgate racialethnic socioeconomic geographic disparities benefiting earlyadopter communities leaving lateadopter communities higher risk83 recently expanding approach types interventions use principles communitybased participatory research working community members understand social cultural context target population identify appropriate settings intervention work local community members design implement intervention interventions adhered principles communitybased participatory research using culturally sensitive approaches conducting interventions settings churches84 barbershops85 using local neighborhood residents health promoters8688 successful promoting healthy behavior change community involvement leadership critical successful inclusive implementation cardiovascular health interventionspublic health interventions populationwide cardiovascular health promotion cvd risk reductionbuilding framework established institute medicines future public health89 centers disease control preventions 10 essential public health services90 aha community guide defines interventions activities community level required populationwide promotion healthy behaviors activities include surveillance education media organizational partnerships assurance personal health services environmental policy changessurveillance assesses describes prevalence optimal cardiovascular health behaviors factors heart disease stroke underlying social physical environmental influences valuable yet incomplete surveillance data social environmental conditions risk factors use preventive services measures morbiditymortality available nationallevel eg behavioral risk factor surveillance survey91 national health interview survey92 national health nutrition examination survey3879 statelevel eg california health interview survey93 countylevel reports94 2007 aha recommended filling critical gaps us surveillance system support prevention management heart disease stroke95 2011 institute medicine recommended department health human services establish coordinated national surveillance system would integrate existing efforts provide cvd data96although surveillance continues strengthened national statelevel systems awaited communities also strive create maintain surveillance programs cardiovascular health local populations surveillance raises communitys awareness social conditions suboptimal behaviors motivating engagement interventions target intervention programs groups greatest burdens surveillance increasingly used identify health disparitiesinequities smaller population subgroups based race ethnicity socioeconomic status disability geographic location97 continuous surveillance extending implementation essential evaluation intervention programseducation individual level via mass media raises awareness literacy burden causes means prevent heart disease stroke creates favorable information environment supporting healthful lifestyle change increasingly electronic media electronic gaming social networking methods used reach adolescents young adults local media may useful education religious organizations community centers worksites surveillance educational interventions may sufficient change behavior communities communities may require additional support community organization healthcare provision environmental change83organizational partnerships important part intervention strategy provide local venues education health services foster resource development broadbased advocacy policies legislation ultimately result permanent changes local environmentassurance personal health services public health strategy recognizes populations need local healthcare providers healthcare providers screen diagnose treatable risk factors hypertension hyperlipidemia promote behavioral change andor prescribe pharmacological regimens required control monitor adherence risk factor goal attainment provide onsite medical services early recognition treatment symptomatic disease healthcare providers also identify patients known cvd treat appropriate cardioprotective pharmacotherapies numerous studies shown compliance medications reduce individual risk98environmental changes policies limited local state national government also required worksites schools religious organizations communitybased organizations healthcare facilities organizations alter rules facilities heart healthy public policy change take several forms including financial legal regulatory trade policies99102 affecting wide range factors promote healthy behavior96 policy changes focused improvements diet physical activity tobacco environments wellness programs improve behaviors reduce risk increase referrals atrisk individuals appropriate servicesthe aha community guide integrates 3 dimensions ie optimal health behaviors community settings public health interventions create comprehensive set opportunities cardiovascular health improvement community level figure 21 555 cube identifies numerous opportunities communities contribute prevention heart disease stroke focusing one optimal behaviorcommunity settingintervention opportunities guide also encourages community leaders view heart disease stroke prevention broadly comprehensivelyevidence base community guide recommendationsclinical evidencebased guidelines developed use standardized classes grades evidence rely heavily randomized clinical trials103 evidence populationbased policies programs strategies fundamentally different relying observational studies community intervention trials sometimes limited statistical power nonetheless would incorrect presume evidencebased recommendations feasible communitylevel interventions indeed systematic reviews literature sources expert panels policy organizations provide solid foundation evidence make recommendations development implementation communitybased programsthe aha community guide summarizes underlying evidence substantiates populationwide recommendations maintenance cardiovascular health table 2 writing group members identified current systematic reviews evidence summaries population goals optimal behavior additional relevant studies identified iterative writing group discussions table 2 also identifies growing number organizations programs objectively frequently assessing communitybased strategies programs department health human services healthy people 2020 task force community preventive services us preventive services task force national prevention strategy us dietary guidelines advisory committee us physical activity guidelines advisory committee office us surgeon general national heart lung blood institutes national program reduce cardiovascular risk ahas get guidelines program guideline advantage program examples organizations programs contribute enormously ability assemble evidence summaries recently american recovery reinvestment act title iv certain provisions affordable care act provided support several additional programs enhance evidence base populationwide chronic disease control including communities putting prevention work community transformation grants patient centered outcomes research institute center medicare medicaid innovation million hearts initiative2432table 2 systematic reviewsevidence summaries recommendations optimal behaviors community leveloptimal behaviorsreviewsummaryrecommendationno tobaccoreduce tobacco usesurgeons general reports104uspstf31iom report tobacco105complete cessation individualsreductions prevalence smoking level public health impact minimalreduce exposure environmental tobacco smokesurgeon general reports55iom report tobacco105curtail sources involuntary exposure environmental tobacco smokehealthy dietary practicescaloriesaha 2020 impact goals4aha diet lifestyle recommendations106aha obesity guidelines1072010 us dietary guidelines108nhlbi integrated guidelines children adolescents19women 16002400 caldmen 20003000 caldcalorie ranges depend age physical activity level balance calorie intake physical activity achieve maintain healthy body weighthealthy body weight adults bmi 25 kgm2healthy body weight youths 218 age bmi 85th percentile based cdc 2000 growth chartsvegetable fruit intakeaha 2020 impact goals4aha diet lifestyle recommendations1062010 us dietary guidelines108at least 45 cupsdwhole grains eg wholewheat bread brown riceaha 2020 impact goals4harris krisetherton 2010572010 us dietary guidelines108at least three 1ozequivalent servings 11 g fiber per 10 g carbohydratefish intake eg wild salmon anchoviesaha 2020 impact goals4aha diet lifestyle recommendations1062010 us dietary guidelines108mozafarrian rimm 200658at least two 35oz servingsweek low mercurysfa tfa cholesterolaha 2020 impact goals4atp iii59aha diet lifestyle recommendations1062010 us dietary guidelines108sfa 7 calories tfa low possible dietary cholesterol 300 mgdsugaraha 2020 impact goals4johnson et al 200961aha 2020 impact goals4150 cald men 100 cald women450 kcal 36 ozwk sugarsweetened beverages soda juicesodiumaha 2020 impact goals4aha sodium statement62iom report sodium intake1091500 mgd sodiumphysically active lifestyle2008 us physical activity guidelines63ahaacsm recommendations67the guide community preventive services1102008 us physical activity guidelines632008 us physical activity guidelines63ahaacsm recommendations67the guide community preventive services1102008 us physical activity guidelines63ahaacsm recommendations67the guide community preventive services1102008 us physical activity guidelines63ahaacsm recommendations67the guide community preventive services110adults 18 age 150 min moderate aerobic activity per week 75 min vigorous physical activity per weekchildren youth 618 age 60 min moderate vigorous aerobic activity daily least 3 7 days week including vigorous physical activityboth adults childrenyouth aerobic activity performed bouts least 10 minminimum 2 dwk resistance exercise maintain improve muscle strength endurance complemented stretchingflexibility exercisessupplement structured exercise increase daily lifestyle activities eg walking active commuting parking farther away stores household chores using