April 2013 Issue

Cardiovascular Health in America — Where Do We Stand?
By Judith C. Thalheimer, RD, LDN
Today’s Dietitian
Vol. 15 No. 4 P. 18

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, coalesces the most recent data on cardiovascular diseases (CVD) and their risk factors into the Heart Disease and Stroke Statistical Update.

The report is available for free on the AHA website (www.heart.org/statistics) to educate and inform researchers, clinicians, policy makers, news organizations, and the general public about the state of our nation’s cardiovascular health. The Heart Disease and Stroke Statistics — 2013 Update, also published in December 2012 in the AHA journal Circulation, provides insight into nutrition professionals’ importance in the fight against CVD.

In 2010, the AHA set a goal to improve Americans’ cardiovascular health by 20% and reduce heart disease 20% by 2020. Major strides have been made in the previous decade, with the rate of CVD deaths falling 32.7% between 1999 and 2009, but CVD still accounts for nearly one-third of the deaths in the United States. According to AHA data, there’s approximately one death attributable to CVD in the United States every 40 seconds.

Tracking and Quantifying CVD
Tracking improvements in cardiovascular health means first quantifying it. Toward this end, the AHA has chosen seven health metrics to track: cholesterol levels, blood pressure, fasting blood glucose, smoking, physical activity, diet pattern, and body weight.

A look at the most recent data indicates that the rates of smoking, high cholesterol, and high blood pressure are down, but obesity and diabetes are on the rise. If these trends continue, the AHA report concludes that heart health will improve by only 6% by 2020, far short of the 20% goal.

“Americans need to move a lot more, eat healthier and less, and manage risk factors as soon as they develop,” says Alan S. Go, MD, chairman of the report’s writing committee and chief of the cardiovascular and metabolic conditions section of the Kaiser Permanente Northern California Division of Research in Oakland. “If not, we’ll quickly lose the momentum we’ve gained in reducing heart attack and stroke rates, and improving survival over the last few decades.”

Poor Eating Habits and Physical Inactivity
The 2013 report indicates that poor eating patterns and a lack of physical activity are the key areas that must be addressed to significantly impact heart health. Currently, 34.6% of US adults are obese. Add in the number of overweight adults, and that’s 68.2%.

Among children aged 2 to 19, 16.9% are obese, and 31.8% are overweight or obese. Over the past three decades, the prevalence of obesity in children aged 6 to 11 has increased from approximately 4% to more than 20%.

The increases in weight aren’t surprising based on the latest information on caloric intake. Data from the National Health and Nutrition Examination Survey indicate that between 1971 and 2004, average total energy consumption among US adults increased by 22% for women and 10% for men. The extra calories are coming primarily from greater average carbohydrate intake, particularly from starches, refined grains, and sugars. Portion sizes are larger; people eat more food and calories at each meal; and people consume more sugar-sweetened beverages, snacks, fast food, and other energy-dense foods than ever before.

While the “calories in” continue to rise, the “calories out” aren’t keeping pace. Thirty-two percent of adults reported that they didn’t engage in aerobic leisure-time physical activity, and 17.7% of adolescent girls and 10% of boys reported that they hadn’t engaged in at least 60 minutes of moderate-to-vigorous physical activity in the previous seven days.

Moreover, 13.8% of adults still have total cholesterol readings of 240 mg/dL or higher; 33% of adults have high blood pressure, and blacks have one of the highest prevalence of high blood pressure (44%) worldwide; 8.3% of adults have diagnosed diabetes, 8.2 million have undiagnosed diabetes, and 38.2% have prediabetes. Although smoking rates have declined in the past four decades, 21.3% of men and 16.7% of women aged 18 and older still smoke cigarettes, and 18.1% of students in grades 9 through 12 smoke.

Nutrition professionals know that poor dietary patterns are associated with significant morbidity, including an increased risk of coronary heart disease. In fact, 13.2% of CVD mortality and 20.6% of ischemic heart disease mortality can be attributed to poor diet. To achieve ideal cardiovascular health, the AHA recommends a diet in line with the Dietary Approaches to Stop Hypertension (DASH). Under these guidelines, adults and children should achieve at least four of the five following recommendations by consuming:

• more than 4 1/2 cups of fruits and vegetables per day;

• more than two 3.5-oz servings of fish per week (preferably oily fish);

• three 1-oz daily servings of fiber-rich whole grains (defined as more than 1.1 g of fiber per 10 g of carbohydrate);

• fewer than 1,500 mg of sodium per day; and

• fewer than 36 oz (450 kcal) of sugar-sweetened beverages.

Only 0.3% of adults and no children have dietary patterns that meet at least four of these five components.

The DASH Diet
Low-sodium diets rich in fruits, vegetables, whole grains, and fish as well as minerals such as potassium have been shown to positively impact multiple cardiovascular risk factors. Low-sodium or low-fat DASH dietary patterns and DASH-type diets that include an increased consumption of either protein or unsaturated fats have been shown to be beneficial. Mediterranean dietary patterns that include either extra-virgin olive oil or mixed nuts can lower systolic blood pressure, plasma glucose, fasting insulin, and other factors. Like DASH, Mediterranean dietary patterns emphasize fruits, vegetables, fish, and whole grains, along with beans, nuts, legumes, olive oil, and red wine in moderation. In general, both dietary patterns include lean proteins such as poultry and low-fat dairy, and limited sweets and red meat.

The 2013 report cites data from studies and meta-analyses that confirm the wide-reaching effects of dietary habits on cardiovascular risk factors, from improving blood pressure, cholesterol levels, glucose levels and weight to more novel risk factors, such as inflammation, cardiac arrhythmias, endothelial cell function, triglyceride levels, lipoprotein levels, and heart rate.

AHA’s Focus on Prevention
The importance of diet in improving cardiovascular health cannot be overstated. Nutrition professionals will continue to play a key role in helping to achieve the AHA’s goals. Based on the findings of the Heart Disease and Stroke Statistics — 2013 Update, the AHA has designed an outreach plan that will emphasize an expanded focus on prevention rather than the treatment of established CVD, the promotion of healthful behaviors throughout the life span, and initiatives aimed at increasing healthful lifestyles in the general population.

“We’re taking a more aggressive and innovative approach, including taking some pages from the playbooks of the public health sector,” says Donna Arnett, PhD, MSPH, president of the AHA and chairperson of the department of epidemiology at the University of Alabama at Birmingham School of Public Health. “We’re focusing on population-based ways to improve health factors for all Americans.”

RDs and DTRs can use the comprehensive data provided by the AHA to improve their work and support the many public policy initiatives being advocated by the AHA to reach our shared goals.

— Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer and community educator.