Population Health: A Strategic ACC Priority

Cover Story | Population health is not easy to define. It is at a complex intersection between an increasingly diverse population, an evolving health care system, traditional public health and elaborate social policies.

Cardiology Magazine

As part of its Strategic Plan, the College has revved up efforts to engage partners and pursue global cardiovascular-related objectives, support members to improve the health of populations, and encourage cardiovascular team-facilitated patient education. In order to help guide the College as it pursues these population health opportunities, the ACC recently formed a Population Health Policy and Health Promotion Committee. In July, the Committee hosted ACC members and external stakeholders at Heart House for a population health retreat, which aimed to define population health and health promotion for the ACC, discuss whether the College is prepared to engage in primary prevention, and prioritize partners and targeted activities related to population health and health promotion in the College.

The meeting convened a diverse array of experts from government agencies, universities, medical specialty societies and private sector partners to discuss primary prevention, health equity and social determinants of health, the changing health care landscape, and the role of primary care professionals in advancing cardiovascular health. The lineup of speakers – which included experts from the Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, U.S. Food and Drug Administration, U.S. Department of Health and Human Services, the White House and more – shared how their organizations are making strides in reducing cardiovascular disease.

The Committee is currently hard at work building a population health agenda for the College that encompasses a holistic view of health promotion. “If we are to successfully contribute to alleviating the cardiovascular disease burden, we must work with our partners to address critical risk factors and design and support policies that generate the greatest health benefit by improving cardiovascular health outcomes,” says Gerard R. Martin, MD, FACC, chair of the ACC Population Health Policy and Health Promotion Committee. “We have only just begun to dip our toes in the population health waters, and there is tremendous enthusiasm by members and partners and numerous opportunities on the horizon for the College.”

Three Approaches to Stratified Health

Valentin Fuster, MD, PhD, MACC

Valentin Fuster, MD, PhD, MACCWhen we are trying to establish goals toward improved cardiovascular health or health promotion on a population-wide scale, it is important to remember that we need unique strategies at different stages of our lives, depending on the varied scientific/physiopathological background and educational/behavioral tools appropriate for each stage.

Because significant challenges exist, I am proposing a strategy for sustaining health throughout a lifetime, which involves a stratified approach at three different age ranges that could be most effective in promoting cardiovascular health or preventing the progression of disease – even among those at highest risk for cardiovascular events. This strategy cannot be employed in the same way at the same time for every individual. These are strategies pertaining to health promotion that my colleagues and I have learned through recent studies and trials across the globe. Read More >>>

As the first approach to stratified health is within the first 25 years of life, it is reasonable to assume that at that stage there is no significant cardiovascular disease yet in most individuals. We have learned that the optimal period of time to motivate behavior in favor of health is between the ages of three to five years. Indeed, there is evolving evidence that our behavior as adults has its roots in the environment that we grew up in from age three to five years. Furthermore, unhealthy diets begin to influence cardiovascular disease markers early in life. Conditions such as dyslipidemia, high blood pressure, impaired glucose tolerance, as well as obesity and metabolic syndrome may become rooted as early as three to five years of age, increasing the risk of development of atherosclerosis in adolescence and early adulthood.

During these ages, educational topics can include how the body and heart work, healthy food habits, physical activity and emotional habits to avoid addictions. In the SI! Program for Cardiovascular Health Promotion in Early Childhood, for example, intervention was designed to be applied at all preschool levels in 24 Madrid, Spain, schools for the purpose of promoting cardiovascular health among children using their proximal environment (school, teachers and families). Improvement was initially demonstrated during the first year of intervention. This program translated into a beneficial effect on adiposity, with maximal effect when started at the earliest age and maintained over three years. The results presented in the Madrid SI! Program align well with those obtained previously in a Colombian initiative. After intervention, Colombian preschoolers were followed-up for 36 months, sustaining the effect toward healthier behaviors and ultimately leading to a nationwide expansion of the program. The critical question will be answered when these children are 15 to 20 years of age. In other words, can intervention at age three to five years affect health behaviors when these children reach adulthood?

For the second opportunity for stratified health, the age range of 25 to 50 years appears to be the right time to evaluate subclinical disease, about which we have been learning a significant amount through noninvasive imaging techniques. In two recent bioimaging studies, we assessed approximately 10,000 asymptomatic adults >40 years of age using multimodality vascular imaging of the coronary arteries with electron-beam computed tomography for calcification and of the carotid arteries with 3-D ultrasound. We found that subclinical atherosclerosis was highly prevalent, detectable in both the coronary and carotid vascular territories (more recently also in the ilio-femoral region) in close to 60 percent of participants. Thus, we concluded that incorporating detection of subclinical atherosclerosis irrespective of anatomic territory, in addition to cardiovascular risk factors, would motivate patients to change their lifestyle. Through the use of advanced imaging technologies, we are now testing in such adult populations with manifested subclinical disease whether addressing risk factor profile through “group therapy” or an intensified and “around-the-clock” personalized approach is more beneficial in terms of changing lifestyle and preventing progression of the disease than the usual conventional means.

Information Graphic

The third opportunity for stratified health is for individuals >50 years, when cardiovascular disease has often begun to manifest itself symptomatically or by an adverse event. It is of value to approach this population by taking into account the total body vasculatures, including the heart and the brain. It has been increasingly recognized that degenerative brain disease is intimately linked to the vasculature and overall burden of atherosclerosis disease. Specifically, the heart-degenerative brain disease axis is perceptible across a very broad spectrum of disease, from macrovascular large-vessel coronary, carotid or ilio-femoral diseases leading to myocardial infarction or stroke, to microvascular small vessel changes causing dementia. Thus, we must make a transition from primarily considering the coronary vessels to looking at the entire individual in terms of systemic cardiovascular disease, which includes the neurovascular region. Furthermore, in the elderly population with already manifested disease, two pharmacological challenges need to be addressed: Can adherence to medication be improved? Can medication be simplified such as with the use of a polypill?

In summary, at every age range, there are specific scientific/physiopathological backgrounds and educational/behavioral tools available to best intervene. Although there have been external pressures to make “medicine” more personalized or precision-based – terms that have yet to be clearly defined – those of us who are actually entrusted to keep people healthy need to start approaching the population with a stratified health strategy.


Fuster is director of Mount Sinai Heart; physician-in-chief of Mount Sinai Hospital; and editor-in-chief of the Journal of the American College of Cardiology.

He spoke on these approaches during ACC’s Population Health Policy retreat in July and received an award from the Population Health Policy and Health Promotion Committee at the retreat for his leadership in changing the landscape and improving patient health through the lifespan.

New Research Focuses on Alleviating the CVD Burden

A comprehensive Population Health Promotion issue recently published in the Journal of the American College of Cardiology (JACC) focuses on issues that broadly impact public health and the prevention of cardiovascular disease and related conditions. Highlights of the JACC Population Health Promotion issue include:

Unsaturated Fats, High-Quality Carbs:
Replacing saturated fats with unsaturated fats and high-quality carbohydrates may have the most impact on reducing the risk of cardiovascular disease, according to a study by Frank B. Hu, MD, PhD, et al. The study found that when saturated fats were replaced with highly processed foods, there was no benefit. “Our findings suggest that when patients are making lifestyle changes to their diets, cardiologists should encourage the consumption of unsaturated fats like vegetable oils, nuts and seeds, as well as healthy carbohydrates such as whole grains,” Hu says. In an accompanying editorial, Robert A. Vogel, MD, FACC, states that “healthfulness clearly lies in the quality or type of both fat and carbohydrate.” Read More >>>

Blood Pressure (BP) and Diabetes:
Elevated BP may be associated with increased risk of diabetes, according to Connor A. Emdin, HBSc, et al. In a prospective analysis of 4.1 million patients without vascular disease or diabetes, 20 mmHg higher systolic BP was found to be associated with a 58 percent higher risk of diabetes, while a 10 mmHg higher diastolic BP was associated with a 52 percent higher risk. “These investigators offer an exceptionally rigorous evaluation of the relation between BP and incident diabetes,” states Donna K. Arnett, MSPH, PhD, in an accompanying editorial comment. “This study provides a strong rationale for continued research into the biological basis and pharmacological implications of the observed association.”

Cardiology Magazine

Smoking Cessation:
An analysis of medical costs associated with atherosclerotic lower extremity peripheral artery disease (PAD) found that health care costs in one year were $18,000 higher in smokers with PAD than non-smokers with the condition. Accordingly, smokers may be more likely to be hospitalized for leg events, heart attack and coronary heart disease related to atherosclerotic PAD than non-smokers with PAD. In an accompanying editorial, Geoffrey D. Barnes, MD, MSc, FACC, and Elizabeth Jackson, MD, MPH, FACC, note the study highlights the urgent need for smoking cessation among PAD patients and that getting patients to quit may improve care and save significant health dollars over the long term.

Impact of Childhood Stress:
A 45-year study of nearly 7,000 people born in a single week in Great Britain in 1958 found psychological distress in childhood – even when conditions improved in adulthood – may be associated with higher risk for cardiovascular disease and diabetes later in life. “This study supports growing evidence that psychological distress contributes to excess risk of cardiovascular and metabolic disease and that effects may be initiated relatively early in life,” says lead author Ashley Winning, ScD, MPH. “Early prevention and intervention strategies focused not only on the child but also on his or her social circumstances may be an effective way to reduce the long-lasting harmful effects of distress.” In an accompanying editorial comment, E. Alison Holman, PhD, FNP, explains that it may not be helpful for clinicians to focus on “managing” known cardiovascular disease risk factors like smoking, obesity, elevated cholesterol and lack of exercise without addressing underlying risk factors that affect patients.

Global Food Consumption:
More than 80 percent of cardiovascular disease deaths occur in low- and middle-income countries, but very little data on the impact of diet on cardiovascular disease exists from these countries. A state-of-the-art review summarizes the evidence relating food to cardiovascular disease and how the global food system contributes to dietary patterns that greatly increase the risks for populations with poor health. The authors identify what an optimal diet for reducing cardiovascular disease looks like – giving the traditional Mediterranean diet as an example – and suggest that it may be possible to recreate this diet in other regions using appropriate similar food replacements based on food availability and preferences.

Fructose and Cardiometabolic Health:
There is compelling evidence that drinking too many sugar-sweetened beverages, which contain added sugars in the form of high fructose corn syrup or sucrose, can lead to excess weight gain and a greater risk of developing type 2 diabetes and cardiovascular disease, according to a research letter by Vasanti S. Malik, ScD, and Frank B. Hu, MD, PhD. The study – the most comprehensive review of the evidence on the health effects of sugar-sweetened beverages to date – also takes a closer look at the unique role fructose may play in the development of these conditions.

Achieving Ideal Cardiovascular Health:
Promotion of a healthy diet and physical activity will likely help in achieving the ideal cardiovascular health goals set by the American Heart Association, according to a research letter from Adnan Younus, MD, et al. In a review of 18 studies related to cardiovascular health metrics, researchers found that diet metrics were suboptimal, while BP and body mass index (BMI) metrics reported less than 50 percent. Focusing efforts on promotion of healthy diet and exercise may indirectly influence BMI, BP and fasting glucose metrics, according to the authors.

Early Healthy Lifestyle Intervention:
Introducing healthy lifestyle behaviors to children in preschool may improve their knowledge, attitude and habits toward a healthy diet and exercise, and may lead to reduced levels of body fat, according to Valentin Fuster, MD, PhD, MACC, editor-in-chief of JACC, who was an author of the study. Through the SI! Program, researchers in Madrid implemented a three-year healthy lifestyle intervention for three to five year olds that used their school, teachers and families to promote cardiovascular health through healthy diet, increased physical activity, understanding of the human body and managing emotions. “We need to focus our care in the opposite stage of life – we need start promoting health at the earliest years … in order to prevent cardiovascular disease,” states Fuster. (See related article, above) In a related editorial comment, Deepak L. Bhatt, MD, MPH, FACC, et al., says the program is groundbreaking, and follow-up studies to further pinpoint the exact mechanisms by which the program achieved positive effects on young children’s health will be vital for implementing the program in other areas and informing the design of future global programs.

Risk Factor Management:
Three cross-sectional surveys of EUROASPIRE show challenges in applying prevention guidelines in clinical practice for acute coronary artery disease patients, according to a research letter from Kornelia Kotseva, MD, PhD, et al. The results of the surveys show increases in obesity and diabetes amongst the patients, while the proportion of persistent smokers remained the same. “The life-saving treatments for acute coronary artery disease … must be matched by modern preventive cardiology programs combining a professional lifestyle intervention with effective risk factor control to reduce total cardiovascular risk,” states Kotseva.


Read the full JACC Population Health Promotion issue at OnlineJACC.org.

Reference

  1. J Am Coll Cardiol. 2015;66(14).

Population Health and Early Career Professionals:

Personalized lifestyle counseling is a skill all fellows in training and early career professionals should learn, according to Joshua Schulman-Marcus, MD, in the issue’s Fellows in Training and Early Career Column. He notes that communicating with patients and families on lifestyle changes has the potential to prevent cardiovascular disease. “Fellows should be offered the opportunity to work with and get advice from nurse practitioners and other health team members, many of whom have deep experience in counseling patients,” comments Schulman-Marcus. “Cardiologists must continue to provide support and resources for behavioral change without judgment and provide this care with consistent emphasis on the critical importance of the patient’s efforts,” states Pamela Morris, MD, FACC, chair of ACC’s Prevention of Cardiovascular Disease Section, in a response.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Clinical Topic Collection: Dyslipidemia, Geriatric Cardiology, Noninvasive Imaging, Prevention, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Imaging, CHD & Pediatrics and Prevention, CHD & Pediatrics and Quality Improvement, Diet, Hypertension, Sleep Apnea

Keywords: ACC Publications, Cardiology Magazine, Adiposity, Adolescent, Aged, Atherosclerosis, Brain, Cardiovascular Diseases, Carotid Arteries, Centers for Disease Control and Prevention (U.S.), Centers for Medicare and Medicaid Services (U.S.), Coronary Vessels, Dementia, Diet, Dyslipidemias, Food Habits, Glucose, Habits, Health Behavior, Health Policy, Health Promotion, Hypertension, Metabolic Syndrome X, Motor Activity, Myocardial Infarction, Obesity, Primary Health Care, Secondary Prevention, Primary Prevention, Private Sector, Psychotherapy, Group, Public Health, Public Policy, Risk Factors, Social Determinants of Health, Stroke, Tomography, United States Food and Drug Administration


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