Trends in cardiovascular disease risk factors by educational level: the Stanford Five-City Project.

BACKGROUND. Trends in blood pressure, smoking, and cholesterol were examined from 1979-1980 through 1985-1986 in four cities in California by level of education (< high school, high school graduate, some college, college or postgraduate). METHODS. Four biennial cross-sectional surveys (n = 6,580) were conducted in two treatment and two control cities to evaluate a 6-year community health education intervention, conducted as part of the Stanford Five-City Project. RESULTS. Over the 8-year study period, men and women ages 25-74 from each educational group in the treatment cities showed significant declines in smoking prevalence and levels of blood pressure and cholesterol (with the exception of cholesterol in women). In general, declines in the least educated group (< high school) were stronger than declines in the most educated group (college or postgraduate). Similar declines occurred in each educational group in control cities. CONCLUSIONS. These results illustrate that persons from all educational levels can modify their risk for CVD and are of particular importance because of the higher prevalence of CVD risk factors among those with less education. The similarity of time trends in treatment as well as control cities suggests that the broad-based, multisource health education efforts in the United States are succeeding across the educational spectrum.     

Cardiovascular risk factors in Mexican American adults: a transcultural analysis of NHANES III, 1988-1994

OBJECTIVES: This study examined the extent to which cardiovascular disease risk factors differ among subgroups of Mexican Americans living in the United States. METHODS: Using data from a national sample (1988-1994) of 1387 Mexican American women and 1404 Mexican American men, aged 25 to 64 years, we examined an estimate of coronary heart disease mortality risk and 5 primary cardiovascular disease risk factors: systolic blood pressure, body mass index, cigarette smoking, non-high-density lipoprotein cholesterol, and type 2 diabetes mellitus. Differences in risk were evaluated by country of birth and primary language spoken. RESULTS: Estimated 10-year coronary heart disease mortality risk per 1000 persons, adjusted for age and education, was highest for US-born Spanish-speaking men and women (27.5 and 11.4, respectively), intermediate for US-born English-speaking men and women (22.5 and 7.0), and lowest for Mexican-born men and women (20.0 and 6.6). A similar pattern of higher risk among US-born Spanish-speaking men and women was demonstrated for each of the 5 cardiovascular disease risk factors. CONCLUSIONS: These findings illustrate the heterogeneity of the Mexican American population and identify a new group at substantial risk for cardiovascular disease and in need of effective heart disease prevention programs.     

Cardiovascular risk factors in Iranian adults according to educational levels: Isfahan healthy heart program

There is abundant evidence that the socioeconomic status (SES) is inversely associated with CVD risk factors. The objective of this study is to describe the distribution of CVD risk factors according to educational level in Iranian adults. A cross-sectional survey was performed on subjects over the age of 19 in three cities. Demographic data, as well as information on educational level and smoking habits was obtained and then height, weight and blood pressure measurement and blood sampling were arranged. Data was analyzed by the Mantel-Haenszel, Kendalls T correlation and multivariate analysis test. Of 9587 subjects, 48% were men and 52% were women, with mean ages of 39.0+/-15.3 and 38.8+/-14.5 years, respectively. All CVD risk factors showed an inverse relationship with educational level in all subjects, except for smoking and low HDL-C in women. High TC and LDL-C and low HDL-C were inversely related to educational level (P<0.05); however, this relationship was not significant with Mantel-Haenszel test in men. The association between CVD risk factors and educational level in women was stronger than in men. The differences found between CVD risk factors with educational level are important and should be considered in programs designed to increase level of education in order to lower CVD risk factors.     

Comparison of baseline fat-related eating behaviors of Puerto Rican,Dominican, Colombian,and Guatemalan participants who joined a cholesterol education project

OBJECTIVE: The objective is to compare baseline fat-related eating behaviors among Hispanic subgroups who joined a cholesterol education research project in New England. DESIGN: Participants attended baseline screenings as part of the study. They had their height, weight, and blood cholesterol measured and completed baseline surveys with demographic, risk factor, dietary, and psychosocial questions. PARTICIPANTS: A total of 370 Puerto Rican, 210 Colombian, 357 Dominican, and 102 Guatemalan subjects participated in the baseline. Main Outcome Measures: Dietary behavior was measured using the Food Habits Questionnaire (FHQ), which was originally developed to assess food choices and preparation patterns related to adopting a low-fat diet. Measures include FHQ fat summary scores (a reflection of total fat intake), fat behavior subscales, and individual fat-related behaviors. ANALYSIS: Analysis of variance was used to compare FHQ fat summary scores and multivariate analysis of variance was used to compare fat behavior scores and individual food item scores for the 4 Hispanic subgroups. Age and gender were covariates in the models. RESULTS: Puerto Rican participants had a significantly higher mean FHQ fat summary score than Dominicans and Guatemalans and a higher prevalence of many fat-related eating behaviors. Although there were some differences by subgroup, the 4 most prevalent fat-related behaviors were similar: cooking with fat/oil, eating higher-fat sweets, eating higher-fat snacks, and eating dinners with meat. CONCLUSIONS AND IMPLICATIONS: Future educational programs and materials for diverse Hispanic audiences in the northeastern United States should include the above issues; however, educational materials and programs ought to be tailored to individuals whenever possible. Efforts may need to focus on Puerto Ricans, who had a higher prevalence of many fat-related behaviors in this study.     

The role of data-driven planning and coalition development in preventing cardiovascular disease.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. Effective programs for the prevention and control of CVD need to include data-based planning and evaluation at the State and local levels. The authors describe the development of data-driven planning and intervention strategies in Missouri. Statewide planning activities have resulted in the formation of an advisory committee and development of a State plan, a resource directory, and training courses. Analysis of mortality data revealed an unusual concentration of CVD deaths in the southeast portion of the State. Local coalitions are being developed in each of six counties in this region to reduce the prevalence of CVD risk factors. A regional behavioral risk factor survey of 1,006 adults identified key risk factors that will be addressed by the coalitions. These data suggested that physical inactivity, obesity, and hypertension are especially acute problems in the area. Key components of the local coalition development included providing localized data and obtaining the strong commitment of the local health departments. Expanded use of chronic disease surveillance data for planning and evaluation will increase the probability that localities, States, and the nation will achieve Year 2000 Health Objectives. The data-based planning process is described as a possible model for use by other States and localities.     

Salud Para Su Corazón: A Community-Based Latino Cardiovascular Disease Prevention and Outreach Model

Cardiovascular disease (CVD) is the leading cause of death for Latinos living in the United States. This population is generally unaware of important lifestyle or behavioral changes that can prevent CVD. The National Heart, Lung, and Blood Institute (NHLBI) designed and implemented Salud para su Corazón (Health for Your Heart), a culturally appropriate, community-based, theory-driven intervention model. NHLBI's goals were: (1) to design an intervention model appropriate to Latino populations; (2) to pilot test the model in a specific community with the objectives of increasing awareness about heart disease, raising knowledge about CVD prevention, and promoting heart-healthy lifestyles; and (3) to disseminate the model and the materials developed to other communities with similar needs. An agency-community partnership, under the leadership of the Community Alliance for Heart Health, guided all stages of the community intervention project. The multimedia bilingual community intervention included television telenovela format public service announcements (PSAs), radio programs, brochures, recipe booklets, charlas, a promotores training manual, and motivational videos. An evaluation survey assessed the impact of the intervention. A pre-post intervention survey was conducted with more than 300 participants, and results showed that the respondents were substantially more aware of risk factors for CVD, and had greatly increased their knowledge of ways to prevent heart disease. Dissemination efforts have resulted in numerous requests by health organizations, universities, and health maintenance organizations (HMOs) for educational materials and communication strategies produced by Salud para su Corazón. In addition, Univision, the largest Spanish-language broadcast television network, is airing the initiative's PSAs. Also, training seminars for promotores are being conducted in differ ent regions of the United States, and several locations are planning to replicate this study.     

The Influence of Socioeconomic Factors on Cardiovascular Disease Risk Factor Development

In the industrialized, urban United States, there is an increasingly strong inverse association of socioeconomic status (SES) and cardiovascular disease (CVD) risk and mortality. The large difference in levels and trends in CVD risk associated with SES indicates a major potential for primordial prevention if carried out at both individual and community levels and with broader socioeconomic improvements.     

Diabetes-related mortality among Mexican Americans, Puerto Ricans, and Cuban Americans in the United States.

OBJECTIVES: Hispanics are the most rapidly growing minority group in the United States, and Mexican Americans, Puerto Ricans and Cuban Americans are the three largest Hispanic subgroups. Among Hispanics, type 2 diabetes is the fifth leading cause of death. This paper examines diabetes-related mortality in Mexican Americans, Puerto Ricans, and Cuban Americans over 35 years of age in the United States during 1996 and 1997. METHODS: Using data from the National Vital Statistics System and the 1990 and 2000 censuses, we calculated age-adjusted and age-specific diabetes-related death rates for Mexican Americans, Puerto Ricans, and Cuban Americans over 35 years of age. Diabetes-related deaths were determined to be any death for which diabetes was coded as either the underlying or contributing cause of death. RESULTS: The diabetes-related mortality rate for Mexican Americans (251 per 100,000) and Puerto Ricans (204 deaths per 100,000) was twice as high as the diabetes-related mortality rate for Cuban Americans (101 deaths per 100,000). Cuban American decedents had the highest proportion of deaths with diabetes coded as the underlying cause of death (44%). After diabetes, heart disease (31%) followed by cancer (8%) and stroke (6%) were the most frequent primary underlying causes of diabetes-related deaths in all three ethnic groups. CONCLUSION: Our analyses of these data demonstrate that diabetes-related mortality differed among Mexican Americans, Puerto Ricans and Cuban Americans more than 35 years of age in the United States in 1996 and 1997. Socioeconomic factors such as low educational attainment and low income may be factors that contributed to the disparities in these mortality rates for different subgroups. Further research is needed to update these findings and to investigate explanatory risk factors. Diversity among Hispanic subgroups has persisted in recent years and should be considered when health policies and services targeted at these populations are developed.     

Training health professionals and lay volunteers to deliver cholesterol screening and education programs

The National Heart, Lung, and Blood Institute of the National Institutes of Health launched the National Cholesterol Education Program (NCEP) in 1985. With the goal of reducing the prevalence of elevated blood cholesterol in the United States, the NCEP aims to raise awareness and understanding in both health professionals and the general public of high blood cholesterol levels as a risk factor for coronary heart disease. Public interest in blood cholesterol measurement has created an enormous market for cholesterol screening and education programs. The importance of quality screening and educational services was recognized by the NCEP, which has urged the training of all personnel involved in public cholesterol screenings. This paper presents models for training lay volunteers and health professionals to deliver quality public screening programs for high blood cholesterol that are consistent with NCEP recommendations. Blood cholesterol screening, counseling, and referral (SCORE) programs are key intervention strategies of the Pawtucket Heart Health Program (PHHP), a cardiovascular disease prevention research program in Pawtucket, RI. This paper describes the PHHP volunteer training and certification program for cholesterol SCOREs and the demographics of screening volunteers. With the goal of improving the quality of cholesterol screening and education programs nationally, the Cholesterol Training Center (CTC) was established in 1988. Using models established by PHHP, the center developed training workshops to help health professionals initiate, update, expand, or enhance training for cholesterol screening and education programs. CTC training protocols and the characteristics of workshop participants are described, and the workshops' effects on participants' knowledge and self-sufficiency are discussed.     

Race/ethnicity, income, major risk factors, and cardiovascular disease mortality

OBJECTIVES: We explored differences between Black and White men for cardiovascular disease (CVD) mortality across major risk factor levels. METHODS: Major CVD risk factors were measured among 300,647 White and 20,223 Black men aged 35 to 57 years who were screened for the Multiple Risk Factor Intervention Trial (MRFIT). Hazard ratios for CVD deaths for Black and White men over 25 years of follow-up were calculated for subgroups stratified according to risk factor levels. RESULTS: CVD was responsible for 2518 deaths among Black men and 30,772 deaths among White men. The age-adjusted Black-to-White CVD hazard ratio was 1.35 (95% confidence interval [CI]=1.29, 1.40); the risk- and income-adjusted ratio was 1.05 (95% CI=1.01, 1.10). CVD mortality rates were dramatically lower in cases of favorable risk profiles. However, fully adjusted Black-to-White CVD hazard ratios within groups at low, intermediate, high, and very high levels of overall risk were 1.76, 1.20, 1.10, and 0.94, respectively. Similar gradients were evident for individual risk factors. CONCLUSIONS: Higher CVD mortality rates among Black men were largely mediated by risk factors and income. These data underscore the need for sustained primordial risk factor prevention among Black men.     

Cadmium exposure and all-cause and cardiovascular mortality in the U.S. general population

Background: Urine cadmium concentrations were associated with all-cause and cardiovascular mortality in men in the 1988–1994 U.S. National Health and Nutrition Examination Survey (NHANES) population. Since 1988, cadmium exposure has decreased substantially in the United States. The associations between blood and urine cadmium and cardiovascular disease (CVD) mortality at more recent levels of exposure are unknown.Objectives: We evaluated the prospective association of blood and urine cadmium concentrations with all-cause and CVD mortality in the 1999–2004 U.S. population.Methods: We followed 8,989 participants who were ≥ 20 years of age for an average of 4.8 years. Hazard ratios for mortality end points comparing the 80th to the 20th percentiles of cadmium distributions were estimated using Cox regression.Results: The multivariable adjusted hazard ratios [95% confidence intervals (CIs)] for blood and urine cadmium were 1.50 (95% CI: 1.07, 2.10) and 1.52 (95% CI: 1.00, 2.29), respectively, for all-cause mortality, 1.69 (95% CI: 1.03, 2.77) and 1.74 (95% CI: 1.07, 2.83) for CVD mortality, 1.98 (95% CI: 1.11, 3.54) and 2.53 (95% CI: 1.54, 4.16) for heart disease mortality, and 1.73 (95% CI: 0.88, 3.40) and 2.09 (95% CI: 1.06, 4.13) for coronary heart disease mortality. The population attributable risks associated with the 80th percentile of the blood (0.80 μg/L) and urine (0.57 μg/g) cadmium distributions were 7.0 and 8.8%, respectively, for all-cause mortality and 7.5 and 9.2%, respectively, for CVD mortalityConclusions: We found strongly suggestive evidence that cadmium, at substantially low levels of exposure, remains an important determinant of all-cause and CVD mortality in a representative sample of U.S. adults. Efforts to further reduce cadmium exposure in the population could contribute to a substantial decrease in CVD disease burden.     

Cardiovascular diseases in Chile

In 1938, Chile became the first developing country to establish a state health system for the prevention of cardiovascular diseases (CVD). Although prevalence of CVD risk factors (smoking, high cholesterol and triglycerides, hypertension, and atherosclerosis) is lower than in industrialized countries, over the last 50 years CVD incidence in Chile has increased considerably. Cardiovascular disease is diagnosed in 25% of outpatients in departments of the National Health Service. Hypertension is the first cause of morbidity among the adult population (10%). Between 1960 and 1980, CVD mortality increased from 14 to comprise 27% of all deaths. Age-specific mortality for ischemic heart disease increased during the same period from 407 to 699 per 100,000 population. Surveys of the general adult population showed a prevalence of hypertension of almost 20%. Community hypertension follow-up programs obtained only 50% compliance, and blood pressure was normalized in only one-third of hypertensive patients. It is probable that the low standard of living may have influenced the poor results of prevention programs.     

Striking variation in coronary heart disease mortality in the United States among black and white women aged 45-54 by state

Coronary heart disease (CHD) is the leading cause of death for women in the United States. There has been a substantial decrease in CHD mortality in the past few decades in the United States for both women and men. The change in lifestyle after World War II may affect the incidence of and mortality from CHD in a more recent birth cohort, such as the 45-54-year-old age group. CHD mortality among women aged 45-54 by state and race in the United States and other countries in 1994 was evaluated. Correlation of the CHD mortality with state-specific and race-specific educational attainment (% of not a high school graduate) and state-specific prevalence of smoking was examined. There was a 2.5-fold difference in CHD mortality (ICD 410-414, 429.2) between black and white women aged 45-54: 78/100,000 for black versus 31/100,000 for white women; a 3-fold difference in CHD mortality among white women by state: 16/100,000 in Colorado versus 53/100,000 in Louisiana; and a 3-fold difference in CHD mortality among black women by state: 45/100,000 in New Jersey versus 124/100,000 in Arkansas. CHD mortality was correlated with educational attainment among white women (r = 0.62, p = 0.001) and with prevalence of smoking (r = 0.39, p = 0.021). There is a large variation in CHD mortality among women aged 45-54 in the United States by race and state. These differences may reflect variations in coronary risk factors. More detailed evaluation of determinants of CHD mortality by area is needed, as are public health programs that can reduce the marked disparity in CHD mortality in the United States.     

The Serostatus Approach to Fighting the HIV Epidemic: prevention strategies for infected individuals.

In the United States, HIV prevention programs have historically tailored activities for specific groups primarily on the basis of behavioral risk factors and demographic characteristics. Through the Serostatus Approach to Fighting the Epidemic (SAFE), the Centers for Disease Control and Prevention is now expanding prevention programs, especially for individuals with HIV, to reduce the risk of transmission as a supplement to current programs that primarily focus on reducing the risk of acquisition of the virus. For individuals with HIV, SAFE comprises action steps that focus on diagnosing all HIV-infected persons, linking them to appropriate high-quality care and prevention services, helping them adhere to treatment regimens, and supporting them in adopting and sustaining HIV risk reduction behavior. SAFE couple a traditional infectious disease control focus on the infected person with behavioral interventions that have been standard for HIV prevention programs.     

Barriers to women's cardiovascular risk knowledge

Cardiovascular disease (CVD) is the leading cause of death for women in the United States, resulting in a greater emphasis on research and methods for addressing issues relating to this health problem both nationally and worldwide. The authors' purpose was to identify barriers to women's cardiovascular risk knowledge, both personal and organizational, through key informant interviews of health leaders at 10 community health organizations. Analysis showed an overall lack of awareness of CVD risk for women. Culture, finance, and lack of awareness and easily accessible programs implicated the importance of physicians as health care providers and educators for women patients.     

Disparities in long-term cardiovascular disease risk by sexual identity: The National Longitudinal Study of Adolescent to Adult Health

ObjectiveTo examine long-term cardiovascular disease (CVD) risk disparities by sexual identity using a nationally representative sample of young adults in the United States.MethodsData include participants in wave 4 (2008/09; ages 24–34 years) of the National Longitudinal Study of Adolescent to Adult Health (7087 females; 6340 males). Sexual identity was self-reported (heterosexual, mostly heterosexual, bisexual, mostly homosexual, homosexual) and a Framingham-based prediction model was used to estimate participants' risk of a CVD event over 30 years. Differences in CVD risk by sexual identity, relative to heterosexuals, were calculated with linear regression models adjusted for age, race/ethnicity, education, and financial distress.ResultsAverage 30-year CVD risk was 17.2% (95% CI: 16.7, 17.7) in males and 9.0% (95% CI: 8.6, 9.3) in females. Compared to heterosexual females, mostly heterosexual (0.8%; 95% CI: 0.2, 1.4) and mostly homosexual females (2.8%; 95% CI: 0.8, 4.9) had higher CVD risk. Bisexual and homosexual females had higher but not statistically significant CVD risk compared to heterosexuals. Among males, differences in CVD risk by sexual identity were not statistically significant.ConclusionSexual identity was associated with CVD risk in sexual minority subgroups. Population- and clinic-based prevention strategies are needed to minimize disparities in subsequent disease.     

Barriers to Women's Cardiovascular Risk Knowledge

Cardiovascular disease (CVD) is the leading cause of death for women in the United States, resulting in a greater emphasis on research and methods for addressing issues relating to this health problem both nationally and worldwide. The authors’ purpose was to identify barriers to women's cardiovascular risk knowledge, both personal and organizational, through key informant interviews of health leaders at 10 community health organizations. Analysis showed an overall lack of awareness of CVD risk for women. Culture, finance, and lack of awareness and easily accessible programs implicated the importance of physicians as health care providers and educators for women patients.     

Changes in cardiovascular disease risk factors among American Indians. The Strong Heart Study

PURPOSE: This study describes changes in cardiovascular disease (CVD) risk factors in older American Indians over a 4-year period. METHODS: The Strong Heart Study, a longitudinal population-based study of CVD and CVD risk factors among American Indians aged 45-74 years, measured CVD risk factors among 3638 members of 13 tribes in three geographic areas during examinations in 1989 to 1991 and 1993 to 1995. RESULTS: Changes in mean low-density lipoprotein (LDL) cholesterol and the prevalence of elevated LDL cholesterol were inconsistent. Mean high- density lipoprotein (HDL) cholesterol decreased, and the prevalence of low HDL cholesterol increased throughout. Mean systolic blood pressure and hypertension rates increased in nearly all center-sex groups, and hypertension awareness and treatment improved. Smoking rates decreased but remained higher than national rates except among Arizona women. Mean weight and percentage body fat decreased in nearly all center-sex groups but the prevalence of obesity did not change significantly in any group. Diabetes and albuminuria prevalence rates increased throughout the study population. The prevalence of alcohol use decreased, but binge drinking remained common in those who continued to drink. CONCLUSIONS: Improvements in management and prevention of hypertension, diabetes, renal disease, and obesity, and programs to further reduce smoking and alcohol abuse, are urgently needed.     

The association between educational level and risk of cardiovascular disease fatality among women with cardiovascular disease.

BACKGROUND: The inverse relation of socioeconomic status with incident cardiovascular diseases (CVDs) has been well established. However, few data are available describing this relation among ethnically diverse women with prevalent CVD. Using education as a proxy for socioeconomic status, we examined its relation to CVD mortality among women with established CVD. SUBJECTS: Data from 2,157 women with CVD at baseline, who participated in nine long-term U.S. cohort studies, were pooled. METHODS: Cox regression models adjusted for history of diabetes mellitus, total cholesterol, systolic and diastolic blood pressure, body mass index, smoking, race/ethnicity, and age at baseline were used to estimate hazard ratios for CVD mortality between non-high school graduates and high school graduates. RESULTS: During a mean follow-up time of 11.5 years, 615 CVD deaths were observed. There was an age-dependent (p = .003) inverse association between education and CVD mortality among women with CVD. At age 60, the risk of dying due to CVD among non-high school graduates was more than twice greater than that of high school graduates (hazard ratio = 2.34; 95% CI 1.27-4.29). At age 65, the hazard ratio decreased to 1.31 (95% CI 1.00-1.71). By age 70, there was no difference in the hazard of dying between high school graduates and nongraduates (hazard ratio = 1.01; 95% CI .85-1.21). CONCLUSIONS: Our results show that among women with CVD, educational level was a significant, and age-dependent, predictor of fatal CVD independent of other traditional risk factors. These women are an important high-risk population to target secondary prevention and educational efforts.     

Cardiovascular risk factors and confounders among nondrinking and moderate-drinking U.S. adults

BACKGROUND: Studies suggest that moderate drinkers have lower cardiovascular disease (CVD) mortality than nondrinkers and heavy drinkers, but there have been no randomized trials on this topic. Although most observational studies control for major cardiac risk factors, CVD is independently associated with other factors that could explain the CVD benefits ascribed to moderate drinking. METHODS: Data from the 2003 Behavioral Risk Factor Surveillance System, a population-based telephone survey of U.S. adults, was used to assess the prevalence of CVD risk factors and potential confounders among moderate drinkers and nondrinkers. Moderate drinkers were defined as men who drank an average of two drinks per day or fewer, or women who drank one drink or fewer per day. RESULTS: After adjusting for age and gender, nondrinkers were more likely to have characteristics associated with increased CVD mortality in terms of demographic factors, social factors, behavioral factors, access to health care, and health-related conditions. Of the 30 CVD-associated factors or groups of factors that we assessed, 27 (90%) were significantly more prevalent among nondrinkers. Among factors with multiple categories (e.g., body weight), those in higher-risk groups were progressively more likely to be nondrinkers. Removing those with poor health status or a history of CVD did not affect the results. CONCLUSIONS: These findings suggest that some or all of the apparent protective effect of moderate alcohol consumption on CVD may be due to residual or unmeasured confounding. Given their limitations, nonrandomized studies about the health effects of moderate drinking should be interpreted with caution, particularly since excessive alcohol consumption is a leading health hazard in the United States.