American Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 Update

Abstract

HomeCirculationVol. 127, No. 16American Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 Update Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBAmerican Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 UpdateA Scientific Statement for Public Health Practitioners, Healthcare Providers, and Health Policy Makers Thomas A. Pearson, MD, PhD, FAHA, Co-Chair, Latha P. Palaniappan, MD, MS, FAHA, Co-Chair, Nancy T. 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 A. Franklin, PhD, FAHA, James M. Galloway, MD, FAHA, David C. GoffJr., MD, PhD, FAHA, Gregory W. Heath, DHSc, MPH, FAHA, Ariel T. Holland Frank, Penny M. Kris-Etherton, PhD, RD, Darwin R. Labarthe, MD, MPH, PhD, FAHA, Joanne M. Murabito, MD, ScM, Ralph L. Sacco, MD, MS, FAHA, Comilla Sasson, MD, MS and Melanie B. Turner, MPHon behalf of the American Heart Association Council on Epidemiology and Prevention Thomas A. PearsonThomas A. Pearson Search for more papers by this author , Latha P. PalaniappanLatha P. Palaniappan Search for more papers by this author , Nancy T. ArtinianNancy T. Artinian Search for more papers by this author , Mercedes R. CarnethonMercedes R. Carnethon Search for more papers by this author , Michael H. CriquiMichael H. Criqui Search for more papers by this author , Stephen R. DanielsStephen R. Daniels Search for more papers by this author , Gregg C. FonarowGregg C. Fonarow Search for more papers by this author , Stephen P. FortmannStephen P. Fortmann Search for more papers by this author , Barry A. FranklinBarry A. Franklin Search for more papers by this author , James M. GallowayJames M. Galloway Search for more papers by this author , David C. GoffJr.David C. GoffJr. Search for more papers by this author , Gregory W. HeathGregory W. Heath Search for more papers by this author , Ariel T. Holland FrankAriel T. Holland Frank Search for more papers by this author , Penny M. Kris-EthertonPenny M. Kris-Etherton Search for more papers by this author , Darwin R. LabartheDarwin R. Labarthe Search for more papers by this author , Joanne M. MurabitoJoanne M. Murabito Search for more papers by this author , Ralph L. SaccoRalph L. Sacco Search for more papers by this author , Comilla SassonComilla Sasson Search for more papers by this author and Melanie B. TurnerMelanie B. Turner Search for more papers by this author and on behalf of the American Heart Association Council on Epidemiology and Prevention Originally published21 Mar 2013https://doi.org/10.1161/CIR.0b013e31828f8a94Circulation. 2013;127:1730–1753Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 IntroductionThe goal of this American Heart Association Guide for Improving Cardiovascular Health at the Community Level (AHA Community Guide) is to provide a comprehensive inventory of evidence-based goals, strategies, and recommendations for cardiovascular disease (CVD) and stroke prevention that can be implemented on a community level. This guide advances the 2003 AHA Community Guide1 and the 2005 AHA statement on guidance for implementation2 by incorporating new evidence for community interventions gained over the past decade, expanding the target audience to include a broader range of community advocates, aligning with the concepts and terminology of the AHA 2020 Impact Goals, and recognizing the contributions of new public and private sector programs involving community interventions.In recent years, expanding arrays of programs and policies have been implemented in increasingly diverse communities to provide tools, strategies, and other best practices to potentially reduce the incidence of initial and recurrent cardiovascular events. The AHA Community Guide complements the AHA statement entitled “Population Approaches to Improve Diet, Physical Activity, and Smoking Habits”3 and supports the AHA 2020 goal4 to “improve the cardiovascular health of all Americans by 20%, while reducing deaths from CVDs and stroke by 20%.” The present AHA Community Guide supports the AHA 2020 goal by identifying exemplary regional or national programs that encourage cardiovascular health behaviors and health factors (formerly addressing risk behaviors and risk factors) from which communities might acquire proven strategies, expertise, and technical assistance for improving cardiovascular health.The AHA Community Guide Complements Existing CVD and Community GuidelinesThe AHA Community Guide seeks to prevent the onset of disease (primary prevention) and to maintain optimal cardiovascular health (primordial prevention) among broader segments of the population. Prior research indicates that using public health strategies such as sodium reduction in processed foods to lower blood pressure,5–8 tobacco laws to promote smoking cessation,9–11 and modification of the built environment to increase physical activity12–14 can preserve optimal levels of these cardiovascular health factors from childhood throughout the life course15,16 or shift the entire distribution of cardiovascular risk to lower levels.17 This public health approach yields lifelong benefits in terms of good health and reduced healthcare costs. The AHA Community Guide complements existing AHA, National Heart, Lung, and Blood Institute, and Centers for Disease Control and Prevention guidelines and initiatives to preserve cardiovascular health and to achieve primary and secondary prevention of heart disease and stroke.18–30 Most of these existing policy statements and guidelines for heart disease and stroke prevention target individuals and healthcare providers. The Centers for Disease Control and Prevention’s Guide to Community Preventive Services27,28 addresses some health behaviors and comorbid conditions (ie, nutrition, physical activity, smoking, and obesity) that are relevant to CVD prevention; however, it does not address a comprehensive set of cardiovascular health factors (omitting, for example, hypertension and hypercholesterolemia). Thus, despite the existing CVD prevention guidelines for individuals and healthcare providers21,22,29,30 and the Guide to Community Preventive Services,31 a comprehensive and up-to-date review of community approaches for CVD prevention is an important and timely contribution to a comprehensive CVD prevention model in the United States. This rationale provides the basis for this updated AHA Community Guide.This guide has the unique opportunity to build upon, to develop synergies with, and to further advance the multiple interventions and policy changes occurring over the past decade. Through the Affordable Care Act and other recent legislation, federal policies have been set in motion to support and enhance community engagement as an essential and unique role in prevention.32 These policies range from implementation of community assessment components for hospitals to the development of Accountable Care Organizations, as well as coverage of preventive health services under public and private insurance, integration of community health workers in many of these programs, and transformation of communities’ policy infrastructure to support cardiovascular health.32Identifying Interventions for Population-wide Cardiovascular Health Promotion and CVD Risk ReductionVarious interventions for population-wide health promotion and risk reduction efforts have been categorized by Frieden33 in a health impact pyramid (Figure 1). At the base of the pyramid are interventions that have the broadest impact on populations (eg, socioeconomic factors), which decreases from bottom to top, and at the top are those that require the greatest individual effort (eg, counseling and education), which decreases from top to bottom.Download figureDownload PowerPointFigure 1. Health impact pyramid. Reproduced from Frieden33 with permission of the publisher. Copyright © 2010, American Public Health Association.The social and environmental origins of CVD have long been recognized as mediated in large part by lifestyles and behaviors that are modifiable. Cardiovascular health in children predicts subsequent cardiometabolic health in adulthood,34,35 affirming the importance of maintaining healthy lifestyle behaviors from early in life. Longitudinal population studies have documented low lifetime risk of heart disease and stroke in people with few or no risk factors.15,36–38 The large reductions in heart disease and stroke mortality in the United States and other high-income countries since the 1960s are partially attributable to population-wide reductions in tobacco use and dietary fat, including saturated fat and cholesterol.39–42 These primordial prevention strategies allow maintenance of optimal cardiovascular health over a longer period of time for a larger portion of the population, consistent with the AHA 2020 goals.4 Considerable new evidence has quantified the relative costs of interventions at the individual versus population level.43,44 According to the World Health Organization, policy and other environmental changes may bring about major reductions in CVD burden in all countries for less than $1 per person per year, whereas costs of individual counseling, drug, or surgical approaches are at least several-fold higher.44The AHA Community Guide recommends interventions targeted at all the strata of the pyramid, with an emphasis on the second level, changing the context to make individuals’ default decisions healthy.33 The improvement in socioeconomic status (first level)33 is a worthy goal for any society, and the AHA Community Guide fully recognizes the critical im