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W2085473648 abstract "HomeCirculationVol. 124, No. 23Public Policy Approaches to the Prevention of Heart Disease and Stroke Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPublic Policy Approaches to the Prevention of Heart Disease and Stroke Thomas A. Pearson Thomas A. PearsonThomas A. Pearson From the University of Rochester School of Medicine and Dentistry, Rochester, NY, and the National Forum for Heart Disease and Stroke Prevention, Atlanta, GA. Search for more papers by this author Originally published6 Dec 2011https://doi.org/10.1161/CIRCULATIONAHA.110.968743Circulation. 2011;124:2560–2571IntroductionThose studying the causes of human disease have long recognized the important roles of social, economic, and environmental factors. Engel's1 biopsychosocial model emphasizes the importance of a hierarchy of systems from molecules to cells, to individuals and families, to societies, and to cultures in the causation of disease and its sequelae. Although specific diseases may vary in the contributions from each system, it is very clear that social and environmental factors contribute strongly to the risk of heart disease and stroke. Blackburn2 provides an extensive compendium of evidence for a significant sociocultural contribution to the cause of the major cardiovascular diseases and the need for intervention at community and societal levels. Such evidence led Rose et al3 to “seek a general change in behavioral norms and in the circumstances which facilitate their adoption.”Many of the interventions in clinical medicine constitute the “high-risk approach,” namely the clinical identification of individuals in that portion of the population at highest risk and their intensive treatment through behavioral or pharmacological means. For example, the detection and treatment of high blood cholesterol according to the Adult Treatment Panel guidelines seek to intensely treat the upper tail of the population distribution to move those high-risk individuals to more moderate levels of risk (Figure 1A).4 American Heart Association guidelines for the primary and secondary prevention of heart disease and stroke largely use the high-risk approach.5,6 In contrast, the population approach to cholesterol reduction seeks to shift the entire curve to a lower risk level through population-wide changes in diet, exercise, and weight management (Figure 1B).4 Both approaches are necessary, although analyses of the 20th century decline in coronary disease mortality suggest that the majority of the decline could be attributable to lifestyle changes in the American diet and the use of tobacco.7,8 For these reasons, the 2003 AHA guidelines for preventing heart disease and stroke at the community level9 have been added to complement clinical guidelines for the treatment of individuals. The Public Health Action Plan to Prevent Heart Disease and Stroke (2003) includes policy and environmental changes affecting the entire US population as a means to change adverse behavioral patterns as the first goal of a comprehensive public health strategy to prevent heart disease and stroke.10 Indeed, recent considerations of the 2010 Affordable Care Act (US Healthcare Reform Legislation) emphasize the need for population-wide change outside the healthcare system,11 citing estimates that only 10% to 15% of preventable deaths in the United States are affected by medical care.12Download figureDownload PowerPointFigure 1. High-risk vs the population approach to cardiovascular risk reduction illustrated for serum cholesterol. A, The high-risk approach seeks to identify persons with serum cholesterol levels >240 mg/dL (solid line) and treat them intensively to reduce the number of high-risk individuals (dashed line). B, The population approach seeks to reduce all people's risk by reducing the entire population's high levels of serum cholesterol (solid line) to lower levels of serum cholesterol (dashed line).4This contribution to the Recent Advances in Preventive Cardiology and Lifestyle Medicine series focuses on interventions that facilitate population-wide cardiovascular health through public policy, environmental change, and legislation. Although policy and legislation may have impacts on other important public health activities such as surveillance, public health education, and individual preventive health services, this review is limited to policy interventions that result in changes in the physical, economic, and social contexts that affect population-wide risk for heart disease and stroke.The Theoretical Basis for Public Policy ApproachesA rich theoretical foundation underpins the population approach to heart disease and stroke prevention. The social ecological theory serves to integrate theories on individual behavior change with the understanding of the role for environmental enhancement and restructuring13 to better understand the interaction between an individual and his or her social and physical environments as a potentially strong influence on health and its determinants. An obvious implication of this interaction is that the enhancement and restructuring of an environment could then beneficially affect large numbers of individuals in an at-risk population. Frieden14 builds on this model with a Health Impact Pyramid in which interventions are made to “change the context to make individuals' default decisions healthy” (Figure 2). In this pyramid, most or all individuals would be affected by a healthier environment in which the individual would have to actively avoid the benefits of the healthier environment.Download figureDownload PowerPointFigure 2. The Health Impact Pyramid identifies a level of intervention in which a large portion of the population benefits but with less individual effort needed, namely that of changes in the environmental context in which healthy options are the default choice.14Such individual-environment interactions need to occur in communities targeted for cardiovascular risk–reducing interventions.15,16 The concept of “diffusion of innovation,” developed by Rogers and Shoemaker,17 may help to explain the wide variation in risk behaviors across communities and populations. The diffusion of innovation concept posits that the social, economic, and educational environment allows some communities or subpopulations within communities to readily adopt recommendations related to cardiovascular health. Such communities will effectively use information about the risk they face and actively engage in behavior change in response to health education campaigns that alter their knowledge and attitudes. These approaches alone have been effective in some communities.18 It is also apparent that other communities with different social, economic, and educational characteristics are resistant to these same interventions, resulting in widening disparities in disease burdens.19,20 For example, after the Surgeon General's reports on the risks of tobacco smoking were released in the 1960s, changes in smoking cessation rates were not evenly distributed across US society, with low-income and low-education strata, as well as residents of the tobacco-producing regions, lagging in their rates of decline in tobacco use.20The combination of the social ecological model and the diffusion of innovation concept suggests that the approaches to early- versus late-adopter populations might need to be very different (Figure 3).15 Early-adopter communities may require only recognition of the health burden of heart disease and stroke, with minimal health education via mass or social media to alter their social norms to lead to change in the risk behavior. On the other hand, for a late-adopter community, additional efforts may be needed to support changes in knowledge and attitudes by additional community-wide efforts or provision of health services. Policy and environmental change in which healthy behaviors would be the default option or other policy-based incentives may be necessary for population-wide behavior change in these late-adopter communities. The social ecological theory emphasizes that such interactions between social and cultural characteristics and environmental modifications may be an effective strategy to alter risk on a population-wide basis rather than only in the privileged strata of society. Elimination of disparities in cardiovascular risk is a primary objective of the Public Health Action Plan to Prevent Heart Disease and Stroke.10Download figureDownload PowerPointFigure 3. Illustration of the need for additional policy and environmental change in late-adopter segments of the population to avoid increasing the disparity in health risk. Early-adopter populations may change their social norms and health behaviors in response to information on health risks. For late-adopter populations, such interventions may not be sufficient, requiring additional organizational and policy interventions to affect behavior change.15The Policy Framework for Population-Wide Heart Disease and Stroke PreventionThe global epidemiology of heart disease and stroke in the latter half of the 20th century identified striking variations in cause-specific mortality rates between developed and developing countries, between developed countries, and even within developed countries.21 The interpretation of these trends emphasized the social and political origins of cardiovascular risk. In response, the International Heart Health Network convened a series of International Heart Health Conferences, which provided a series of declarations related to population-wide heart health policies. The Victoria Declaration in 1992 called on governments and the private sector to educate and coordinate public efforts to slow the growing global epidemic of heart disease and stroke.22 The Catalonia Declaration in 1996 discussed the resources and assets needed as an investment in heart health programs23 and identified 141 examples of successful, sustainable programs and 81 case studies of heart health programs.24 The Singapore Declaration in 1998 especially described the need for the political will to create a policy infrastructure as a prerequisite to national programs to control cardiovascular disease.25 The Osaka Declaration in 2001 emphasized factors originating outside the health sector that serve as impediments to heart health.26 The Milan Declaration further described technological approaches to improvement in cardiovascular risk.27 These documents have been pulled together in the Policy Framework for Heart Health,28 which integrates more than a decade of discussion about policy approaches to heart disease. One striking conclusion of these documents is the need to involve a much broader partnership beyond the health and life science sectors, including governmental and private sector agencies dealing with education, trade and commerce, culture, recreation, and agriculture. For a policy infrastructure supportive of population risk reduction, all these sectors must be engaged.Conceptual Approach to Population-Wide Heart Disease and Stroke PreventionIn the AHA guidelines for preventing heart disease and stroke at the community level,9 a 3-dimensional model was proposed as a simplified approach to the complex task of population-wide intervention to reduce heart disease and stroke risks (Figure 4). The 3 dimensions include the risk behaviors targeted for modification, the community setting in which the intervention would take place, and the essential public health services that constitute the interventions in the community.Download figureDownload PowerPointFigure 4. Conceptual framework for population-wide cardiovascular risk behavior change, showing 3 dimensions for consideration: the risk factor or risk behavior targeted for change, the community setting in which the intervention would be implemented, and the type of public health intervention or service used, including policy legislative strategies.9The risk behaviors targeted for intervention are simplified for the framework but can be expanded with more specific details (Table 1). In general, the lifestyle habits of a calorie-balanced diet low in saturated and trans fats and sodium, regular exercise, and avoidance of tobacco have long been identified as predictors of low levels of risk factors and subsequent heart disease and stroke.29,30 The risk behaviors related to hyperlipidemia and hypertension deal with the population levels of compliance with evidence-based recommendations for screening and diagnosis and the adherence to lifestyle and drug interventions31,32 rather than adherence of healthcare providers or health systems to those clinical guidelines for high blood pressure and high blood cholesterol. The population-wide behaviors targeted for early recognition for symptoms of heart disease and stroke entail individuals' knowledge of the signs of heart attack and stroke and their presentation to healthcare providers immediately after the acute onset of symptoms so as to maximally benefit from evidence-based interventions for acute coronary syndromes and ischemic stroke. Population-wide education in resuscitation methods, including the use of community-based external defibrillator technologies, may also be a focus of policies to ensure access to trained personnel and resuscitation technology.Table 1. Risk Behaviors Targeted for Policy Interventions to Reduce the Risk of Heart Disease and Stroke at the Community LevelDiet High saturated fat, trans fat, and cholesterol High sodium Excessive calories Heavy alcohol consumptionSedentary lifestyle Work related, including transportation to/from work Local use of transportation Leisure relatedTobacco Smoking Environmental tobacco smokeHyperlipidemia and hypertension Compliance with screening and diagnosis Adherence with treatment recommendationsDelayed recognition and treatment of symptomatic disease Presentation for diagnosis and treatment Emergency out-of-hospital care by first respondersThe 5 community settings for policy intervention deal with the places where people live, work, and play, namely whole communities, schools and children's services, religious organizations, healthcare facilities, and worksites. The 5 settings represent the social units where most community trials have been conducted as feasible units in which to modify cardiovascular risk in large numbers of persons.33The essential public health services use those functions used by public health agencies to modify population-wide risk behaviors.34 The important roles of surveillance, education and media, organizational partnerships, and assurance of personal health services in changing population-wide behavior are beyond the scope of this review, although the interactions of these functions with policy and legislation are discussed briefly.A further delineation of policy and legislative approaches has been provided by a Committee on Preventing the Global Epidemic of Cardiovascular Disease of the Institute of Medicine.35 Its conceptual model includes more detail on the determinants of cardiovascular health and emphasizes the roles of health education/communication and healthcare delivery (Figure 5). The model also identifies financial, legal, regulatory, and trade policies as 4 specific policy approaches that enable individuals and communities to make and maintain healthful choices. Most of these policy approaches deal with reducing access to or promoting the use of healthy alternatives to the deleterious health behaviors listed in Table 1. Likewise, many of the policy approaches can be carried out in whole geopolitical units but also may focus on more targeted community settings such as schools or children/youth organizations, worksites, religious organizations, or healthcare settings.Download figureDownload PowerPointFigure 5. A comprehensive strategy to address cardiovascular disease from the Institute of Medicine.35 The important role of policy is identified and subdivided into 4 approaches.The combination of Figures 4 and 5 then allows the development of a conceptual framework for consideration of policy approaches to heart disease and stroke prevention (Figure 6). The risk behaviors targeted for change remain those with the epidemiological evidence identifying them as determinants of heart disease and stroke, although the Institute of Medicine model appropriately describes a more complex set of determinants of these behavioral risks.35 The inclusion of the 5 community settings emphasizes that not all policies originate in governmental agencies. Employers, healthcare providers, religious organizations, and educational institutions can institute their own policies affecting their members, either in response to a government policy or on their own volition. An employer's commitment to providing a low-saturated/trans-fat and low-sodium food service, incentives for physical activity during the workday, strict clean air regulations, access to screening programs for hypertension and hyperlipidemia, and instruction on cardiopulmonary resuscitation and use of external defibrillators that are accessible at the worksite would be an example of private sector investment to heart-healthy behavior change similar to those encompassing whole communities enacted by local governments.Download figureDownload PowerPointFigure 6. A conceptual framework for policy approaches to facilitate population-wide cardiovascular risk behavior change, emphasizing consideration of the 4 policy approaches35 for 5 risk behavior clusters across 5 community settings.9The 4 policy approaches—financial, legal, regulatory, and trade policies—also provide insight into more specific strategies to reduce risk behaviors in each of the community settings. All 100 cells (5 settings×5 behaviors×4 policy approaches) may not have current applications but provide a framework to consider new ones. Financial policies would be those that increase the monetary costs of deleterious behaviors (eg, taxation of tobacco) or reduce the monetary cost of healthy alternatives (eg, price supports for fruits and vegetables). Legal policies would be those that inhibit under the force of law the exposure of the population to risks, with penalties (fines, incarceration) incurred on being accused and found guilty of violating a law (eg, smoking in a tobacco-restricted area). Within the tort system, organizations exposing persons to risk can also risk civil lawsuits and financial settlements (eg, tobacco smoke exposure to airline flight crews). Regulatory policies would be those that set standards for various determinants of risk (air quality, trans fat content of food) and the requirements for accurate communication of risks such as food labeling for sodium, saturated fat, and trans fat content of foods. Organizations not meeting standards could face fines or discontinuation of sales unless they meet the standards. Therefore, legal and regulatory policies overlap. Trade and marketing policies would be those laws affecting the production, importation/exportation, buying, and selling of products that affect the risk behaviors (eg, agricultural policies to encourage fruit, vegetable, and fish production; marketing of food, drink, and tobacco).Factors Initiating and Influencing Policy ChangeAlthough surveillance, educational media, organizational partnerships, and assurances of personal health services are not the focus of this discussion of policy approaches, their important interactions with policy formulation and implementation should not be overlooked. Surveillance of the population burdens of heart disease and stroke borne by communities and nations is an obvious driver of policy, especially those data that document inequities in disease incidence and mortalities across demographic and geographic groups, as well as secular trends showing increasing disease prevalence, disability, and cost. Moreover, the effective use of media and other health education modalities is an important means to grow grassroots support for environmental change through legislative action by policy makers. Organizational partnerships are frequently conduits for advocacy for policy change, especially on behalf of governmental organizations constrained from lobbying policy makers directly. Finally, healthcare facilities have access to cardiovascular disease policies in the form of evidence-based clinical guidelines. Clinicians often can be effective advocates and credible content experts in support of policy change.The effectiveness of behavior change and therapeutic interventions in individuals supports the evidence base for population-wide strategies that accomplish similar changes in cardiovascular risk. Conversely, a strong policy infrastructure should also benefit other individual and public health functions, especially personal health services. There continues to be a dearth of research describing the interactions between public health policies and individual healthcare policies to promote heart disease and stroke prevention. Although the coexistence of policies ensuring a heart-healthy and stroke-free environment should logically facilitate healthcare providers' efforts to provide individuals with preventive services, few well-designed studies have been able to examine this potentially rich interaction between the high-risk and population approaches.Evidence of Policy EffectivenessEvidence from well-designed, observational, and randomized studies has become established as a strict prerequisite for clinical guidelines since the 1990s, and similar demands for a scientific basis for making public health decisions have followed.36,37 Yet, it has been realized that, although clinical medicine depends overwhelmingly on the results of randomized clinical trials, the nature of public health evidence may need to be broader, not only because of logistical and statistical issues related to population-wide intervention studies but also so that additional observational and qualitative studies that add valuable experience to the evidence base are not overlooked.38 The Osaka Declaration identified a number of fundamental differences between the evidence bases supporting individual (clinical) versus community approaches to the prevention of heart disease and stroke (Table 2).26 The Community Preventive Services Task Force has incorporated this broader and sometimes judgmental perspective into its recommendations,39 including economic evaluations.40 It may be safe to conclude that policy makers continue to face gaps in the evidence base for population-wide interventions to meet their needs, in part owing to the infrequency of formal evaluations of implemented policies and the relative rarity of publication in venues other than official governmental documents. Nonetheless, the availability of evidence for effectiveness should certainly weigh heavily in favoring an evidence-based policy over others without such evidence.Table 2. Comparison of Individual and Community Approaches for Cardiovascular Disease Prevention*Individual: Clinical PracticeCommunity: Population Approaches and Health PromotionThe standards are randomized, controlled trialsStandards are outcome and process evaluation, using quantitative and qualitative methodsPatients are individualsThe client is the communityLess than therapeutic dose is unacceptablePreventive dose is rarely appliedEasier to treat an individualDifficult to scale up health promotion programs that reach the whole populationOutcomes of interventions are individual changeOutcomes are to change the social norms, environments, and behavior of entire populationsInterventions can focus on most factors relevant to the outcomeInterventions rarely take on social determinants external to the community*The Osaka Declaration.25Another consideration regarding the effectiveness of an evidence-based policy is the method of implementation and the context in which it is implemented rather that the policy itself. As with clinical guidelines based on randomized efficacy studies performed in ideal settings, the implementation of a public policy may have very different outcomes across local, state, national, and international venues and contexts. The assessment of the degree to which a policy might be applicable is built into the research, effectiveness, adoption, implementation, and maintenance program evaluation scheme of Green and Glasgow.41 In the case of an ineffective policy, these 5 steps are a useful framework for policy reevaluation. The complexity of the contextual setting in which policies are implemented and evaluated is illustrated by Kumanyika et al42 in the description of the policy frameworks for the control of the obesity epidemic (Figure 7). This important disease not only relates to 2 risk behaviors (excessive caloric intake and sedentary lifestyle) but also is affected by many environmental and behavioral factors that in turn might be addressed by policies at the local, regional, national, and international levels. The interactions between a public health policy; other policies involving the built environment, transportation, and agriculture; and other environmental factors may explain the success or failure of the same policy implemented in different locales.40Download figureDownload PowerPointFigure 7. Illustration of the complexity of the context in which policy-driven behavior change may take place, including the determinants of obesity, the levels of society involved, and their multiple interactions (from Reference 42 as cited in Reference 43).Policy Approaches to Support Population-Wide Change in Specific Risk BehaviorsIn general, policy approaches to reduce heart disease and stroke risk at the population level involve the restriction of access to the deleterious health behaviors listed on Table 1 and/or the promotion of access to alternative healthy behaviors. In this section, the policy approaches to altering the risk behaviors are discussed from the perspective of type of public policy approach used, namely financial, legal, regulatory, or trade policies. Examples of these policies are drawn from the Public Health Action Plan to Prevent Heart Disease and Stroke,10 Guide to Community Preventive Services44 from the United States, the National Institute for Health and Clinical Excellence 2010 Public Health Guidance for the United Kingdom,45 and individual policy studies.DietA strong evidence base exists for specific dietary policies relevant to cardiovascular health. From this evidence, the 2010 US Dietary Guidelines Advisory Committee46 recommends (1) the reduction of saturated fat to <7% of calories with replacement of saturated fat calories with monounsaturated or polyunsaturated fats; (2) elimination of industrial trans fatty acids; (3) reduction of dietary sodium to 1500 m/d; (4) balance of calorie intake with expenditure; (5) limitation of alcohol to 2 drinks per day for men and 1 drink per day for women and no more than 4 drinks in a single day for men or 3 drinks in a single day for women; and (6) consumption of 2 servings of seafood per week providing 250 mg/d of N-3 fatty acids. As described in this report,46 wide gaps remain between those recommended and those assessed by recurrent nutritional surveys over the past 20 years. The estimated benefits to health indicators and related medical care costs is potentially enormous.47Many policy approaches exist for population-wide dietary change (Table 3). Price supports for foods low in sodium, saturated fat, or trans fat and the removal of price supports for foods high in sodium, saturated fat, or trans fat have been proposed by National Institute for Health and Clinical Excellence (NICE) in the United Kingdom45 on the basis of a number of countries enacting legislation of this nature and then experiencing impressive reductions in heart disease and stroke. Poland ended price supports for butter and high-fat meats and allowed importation of fruits, vegetables, and low-saturated-fat margarines after the fall of the Iron Curtain in the early 1990s. This was followed by a rapid 26% decrease in coronary disease mortality in that country.48 Mauritius introduced legislation to make mandatory the substitution of polyunsaturated oils for cooking in place of those high in saturated fats, with a rapid fall in cardiovascular disease deaths.49 Taxation of high-fat foods in the United States has been proposed but is highly controversial. Nonetheless, alteration of costs of foods, either healthy or unhealthy, appears to affect purchase and consumption.Table 3. Policy Approaches to Improve Population-Wide Dietary BehaviorsPolicy ApproachesWhole CommunitiesSchools/ChildrenReligious OrganizationsHealthcare FacilitiesWorksitesFinancial policies Provide price supports for low-sodium, low–trans fat, low–saturated fat foodsXXXX Tax high-sodium, high–trans fat, high–saturated fat foodsX Tax alcoholic beveragesX Provide grants and loans for healthy food retailers in food desertsXXXLegal policies Ban industrial trans fat from human consumptionX Limit hours and density of alcohol retailersXX Limit legal age of alcohol purchase and consumptionXRegulatory approaches Create regulations to limit the number and hours of fast-food outlets near schoolsXX Develop limits for sodium and saturated fat for preserved foodsX Develop labeling for shelves or packaging of fresh foodsX Label food to identify those high in sodium, saturated fat, and trans fatXXX Limit percent of trans fats in fats and oils used in food preparationXXX Require offerings of healthy foods and beverages in vending machinesXXX Require healthy food choices in school mealsXXTrade and marketing Restrict nonbroadcast advertising and promotion of foods high in so" @default.
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W2085473648 title "Public Policy Approaches to the Prevention of Heart Disease and Stroke" @default.
W2085473648 cites W1590645825 @default.
W2085473648 cites W1600657626 @default.
W2085473648 cites W1965552035 @default.
W2085473648 cites W1967553295 @default.
W2085473648 cites W1981925396 @default.
W2085473648 cites W1984963575 @default.
W2085473648 cites W1989302358 @default.
W2085473648 cites W1996883717 @default.
W2085473648 cites W1999658872 @default.
W2085473648 cites W2009543941 @default.
W2085473648 cites W2010402677 @default.
W2085473648 cites W2027566272 @default.
W2085473648 cites W2042502048 @default.
W2085473648 cites W2044600308 @default.
W2085473648 cites W2059307302 @default.
W2085473648 cites W2061606717 @default.
W2085473648 cites W2065591601 @default.
W2085473648 cites W2077838582 @default.
W2085473648 cites W2095017107 @default.
W2085473648 cites W2096784269 @default.
W2085473648 cites W2103080848 @default.
W2085473648 cites W2103386360 @default.
W2085473648 cites W2112177209 @default.
W2085473648 cites W2112858809 @default.
W2085473648 cites W2121691820 @default.
W2085473648 cites W2126478137 @default.
W2085473648 cites W2128546081 @default.
W2085473648 cites W2132884480 @default.
W2085473648 cites W2140251732 @default.
W2085473648 cites W2140492377 @default.
W2085473648 cites W2143321563 @default.
W2085473648 cites W2144759387 @default.
W2085473648 cites W2151186028 @default.
W2085473648 cites W2154153544 @default.
W2085473648 cites W2154658084 @default.
W2085473648 cites W2156849088 @default.
W2085473648 cites W2159452348 @default.
W2085473648 cites W2159478271 @default.
W2085473648 cites W2161716222 @default.
W2085473648 cites W2161835420 @default.
W2085473648 cites W2167067204 @default.
W2085473648 cites W2167619051 @default.
W2085473648 cites W2168986321 @default.
W2085473648 cites W2179535556 @default.
W2085473648 cites W2179965972 @default.
W2085473648 cites W2332987513 @default.
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