Public Health Cardiovascular Health and Disease
by
Darwin R. Labarthe
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 28 May 2013
  • DOI: 10.1093/obo/9780199756797-0069

Introduction

In the context of public health, “heart disease” represents a number of circulatory system disorders that are common and serious, and whose prevention has great potential for improving population health. “Heart disease and stroke” and “cardiovascular disease” (CVD) are terms meant to denote this group of disorders beyond “heart disease” alone. Heart disease and stroke are first- and second-leading causes of death worldwide, first and third in lost years of life, and first and fourth in disability-adjusted years of life lost. (For this bibliography, “CVD” is used for convenience, except where diseases or conditions such as coronary heart disease, stroke, heart failure, hypertension, and others are referenced specifically.) This bibliography is intended to identify sources of information regarding CVD epidemiology and prevention, as a point of departure for research on related topics. It includes selected classic references, more recent publications, and online sources that can be accessed at any time for current updates. CVD contributes substantially to the public health burden of chronic diseases, or “noncommunicable diseases” (NCDs), comprising cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes, whose aggregate burden is increasingly recognized at national and global levels. Citations addressing this broader group of major chronic diseases are inherently relevant to CVD. If not always explicitly so, and they are represented here, though very selectively. Discussion of CVD from a public health perspective includes consideration of how scientific evidence is evaluated as a basis for policy, and how policy once developed serves as a basis for action. The citations addressed here, in sequence, document the importance of CVD for global health; describe the major cardiovascular disorders and patterns in their occurrence; present epidemiologic evidence regarding their main determinants; discuss concepts of causation, prevention, clinical guidelines, and public health policy and practice; and point to research directions for the future. (It should be noted that social and cultural factors in causation and prevention of CVD are addressed in multiple selections throughout this article [due to their intersection with virtually every topic], rather than as a separate topic of its own; this is especially true of selections in the General Overviews and Global Perspective sections).

General Overviews

A comprehensive, single-author, public health overview of cardiovascular disease (CVD) epidemiology and prevention is provided by Labarthe 2011 (the present bibliography is similarly organized). Remington, et al. 2010 presents an update of the standard public health text on chronic diseases, including CVD; cross-cutting issues relevant to multiple chronic conditions will become evident to the reader. Murray and Lopez 1996 provides a unique insight to the burden of CVD and other major diseases globally, projected from 1990 to 2020, based on available data and extensive modeling. The economic importance of preventing noncommunicable diseases (NCDs) is presented in World Health Organization 2005. An edited volume, Marmot and Elliott 2005, updates a 1992 edition with fifty-one wide-ranging chapters reflecting views of a large number of contributors worldwide. Gaziano, et al. 2006 presents a chapter on CVD within a major World Bank publication on disease control priorities for developing countries, and it includes economic and policy analysis. Mathers, et al. 2006 demonstrates the magnitude of the burdens of CVD and other major diseases, with analysis specific to high-, middle-, and low-income regions throughout the world.

  • Gaziano, T. A., K. S. Reddy, F. Paccaud, S. Horton, and V. Chaturvedi. 2006. Cardiovascular disease. In Disease control priorities in developing countries. 2d ed. Edited by D. T. Jamison, J. G. Breman, A. R. Measham, et al., 645–662. Washington, DC: World Bank.

    DOI: 10.1596/978-0-8213-6179-5/Chpt-33Save Citation »Export Citation »E-mail Citation »

    Ischemic heart disease (IHD), stroke, and congestive heart failure (CHF, elsewhere simply heart failure, or HF) are addressed as to their regional and global distributions. Economic evaluations of alternative intervention strategies are discussed in this chapter; several other chapters present methods of economic analysis and principles of global health policy. Copublished with Oxford University Press.

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    • Labarthe, D. R. 2011. Epidemiology and prevention of cardiovascular diseases: A global challenge. 2d ed. Sudbury MA: Jones and Bartlett.

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      This single-author text presents a unified public health perspective. The epidemiology of major cardiovascular diseases, Definitions and both national and global patterns of occurrence, their causes and means of prevention, and the process of developing recommendations for public health policy and practice at national and global levels are reviewed.

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      • Marmot, M., and P. Elliott, eds. 2005. Coronary heart disease epidemiology: From aetiology to public health. 2d ed. Oxford: Oxford Univ. Press.

        DOI: 10.1093/acprof:oso/9780198525738.001.0001Save Citation »Export Citation »E-mail Citation »

        Perspectives of many contributors are represented in this collection of fifty-one separately authored chapters on a wide range of topics specific to coronary heart disease (CHD), updating the 1992 first edition.

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        • Mathers, C. D., A. D. Lopez, and C. J. L. Murray. 2006. The burden of disease and mortality by condition: Data, methods, and results for 2001. In Global burden of disease and risk factors. Edited by A. D. Lopez, C. D. Mathers, M. Ezzati, D. T. Jamison, and C. J. L. Murray, 45–240. Washington, DC: World Bank.

          DOI: 10.1596/978-0-8213-6262-4Save Citation »Export Citation »E-mail Citation »

          This sequel to the 1996 first edition updates estimates of regional and global morbidity and mortality and adds extensive discussion of attributable risks of common underlying factors for the major chronic diseases. Estimated numbers of deaths attributable to these causes are presented for high-, middle-, and low-income countries.  

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          • Murray, C. J. L., and A. D. Lopez. 1996. Alternative visions of the future: projecting mortality and disability, 1990–2020. In The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Edited by C. J. L. Murray and A. D. Lopez. Cambridge, MA: Harvard School of Public Health.

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            This collaboration by the World Bank, World Health Organization, the Harvard School of Public Health reflects growing concern and awareness of the chronic diseases as a global health problem. Past trends and contemporary models identify heart disease and stroke as the first and second leading causes of death in 1990 and 2020.

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            • Remington, P. L., R. C. Brownson, and M. V. Wegner, eds. 2010. Chronic disease epidemiology and control. 3d ed. Washington, DC: American Public Health Association,

              DOI: 10.2105/9780875531922Save Citation »Export Citation »E-mail Citation »

              This standard reference work on public health aspects of chronic diseases, including CVD, has recently appeared in a new edition. Additional chapters on epidemiology and control of chronic diseases are relevant to CVD and will also be of value to readers.

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              • World Health Organization. 2005. Preventing chronic diseases: A vital investment. Geneva, Switzerland: World Health Organization.

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                Further investigation of the economic costs of chronic diseases provides estimates of the current (2005) burden of “indirect costs”—those attributable to lost wages and productivity—due to cardiovascular disease and diabetes, and projects great increases in economic burden to 2015 across eleven countries (for China, a sevenfold increase).

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                Global Perspective

                The concept of “epidemiologic transition” has influenced the understanding of the increasing burden of cardiovascular disease (CVD), especially in developing countries, since its introduction in Omran 1971. It has arguably misdirected that understanding, however, due to its focus on proportionate, not absolute, mortality, which underestimates the actual importance of CVD when other causes of death remain dominant in frequency. Howson, et al. 1998 pointed to the overlooked need for CVD prevention in developing countries. Leeder, et al. 2004 emphasized this point and the urgency of public health action after the Millennium Development Goals failed to acknowledge CVD or other noncommunicable diseases (NCDs) as having global health importance. The pictorial atlas in Mackay and Mensah 2004 graphically presents worldwide variation around a universally high burden of CVD. Fuster and Kelly 2010, an IOM report on global cardiovascular health promotion, provides a detailed discussion of potential interventions, priority setting, and useful analogies to long-term management of HIV/AIDS as a model for CVD prevention. The World Health Organization’s country profiles on NCDs (World Health Organization 2011) presents a unique compendium of one-page data summaries for 193 countries regarding NCD morbidity, mortality, behaviors, and risk factors. United Nations 2011 is a landmark documentation of high-level concern about NCDs and a commitment to specific actions. Labarthe and Dunbar 2012 reviews strategies of cardiovascular health promotion and CVD prevention worldwide, as well as new opportunities given UN attention to this area.

                The Major Cardiovascular Diseases

                Cardiovascular disease (CVD) is dominated in most of the world by coronary heart disease (CHD), also known as ischemic heart disease (IHD), and stroke, due to their contributions to mortality, morbidity, and economic impact, as documented in Labarthe 1998. This edition of the public health text on CVD epidemiology and prevention includes, in addition to CHD, stroke, heart failure, and other atherosclerotic and hypertensive diseases; and reviews of such other cardiovascular conditions, such as rheumatic heart disease and Chagas disease, which add significantly to the CVD burden in some countries. Congenital malformations and cardiac and vascular defects are also prominent in some regions of the world and are of concern wherever they occur. These other important conditions are beyond the scope of this bibliography, but they are of great potential interest, so they are noted here.

                • Labarthe, D. R.. 1998. Epidemiology and prevention of cardiovascular diseases: A Global challenge. Gaithersburg, MD: Aspen.

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                  This first edition of a public health text on epidemiology and prevention of CVD includes chapters on rheumatic heart disease, Chagas disease, congenital heart disease, Kawasaki disease, and cardiomyopathies, current through the late 1990s. Applicable prevention policies and practices and research priorities are also discussed. For second edition, see Labarthe 2011, cited under General Overviews.

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                  Coronary Heart Disease

                  Keys 1980 reported on the unique Seven Countries Study, in which factors were studied to account for population differences—in contrast to individual-level differences—in coronary heart disease (CHD) event rates; numerous reports from this major study have appeared over subsequent decades, up to the present. Stamler, et al. 1999 pooled large cohort studies to find sufficient numbers of persons at low CHD risk and determine the effect of this uncommon status on long-term mortality and life expectancy. Three reports from the WHO MONICA (MONItoring Trends and Determinants in CArdiovascular Disease) Project, by Tunstall-Pedoe and others, (Tunstall-Pedoe 1999, Tunstall-Pedoe 2000, and Kuulasmaa, et al. 2000), demonstrate the requirements of a complex study design and challenging analysis to disentangle determinants of variation in CVD trends across countries, such as changes in event rates, case fatality, and risk factors. Luepker, et al. 2004 provides an update on a much earlier WHO publication serving to guide investigators in the design of cardiovascular population surveys. The INTERHEART study, reported on in Yusuf, et al. 2004, included populations in fifty-two countries around the world and demonstrated methods for standardizing and executing multinational case-comparison studies of CHD.

                  • Keys, A. 1980. Seven countries: A multivariate analysis of death and coronary heart disease. Cambridge, MA: Harvard Univ. Press.

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                    This classic study of sixteen cohorts of middle-aged men sampled within seven countries in Europe, Japan, and the United States, provided strong early evidence regarding factors to explain higher versus lower CHD event rates among geographically distinct populations. The work provided settings for training generations of CVD epidemiologists as well.

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                    • Kuulasmaa, K., H. Tunstall-Pedoe, A. Dobson, et al. 2000. Estimation of contribution of changes in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations. Lancet 355.9205: 675–687.

                      DOI: 10.1016/S0140-6736(99)11180-2Save Citation »Export Citation »E-mail Citation »

                      Third in this multireport analysis was the finding that risk factor change was generally favorable across populations, generally offset to some degree by increasing overweight and obesity, and less precisely measured (hence less conclusively evaluated) than measures of treatment.

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                      • Luepker, R. V., A. Evans, P. McKeigue, and K. S. Reddy. 2004. Cardiovascular survey methods. 3d ed. Geneva, Switzerland: World Health Organization.

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                        Standardization of methods for epidemiologic studies of CVD was boosted by the 1968 predecessor to this recent update, also published by WHO. This version reflects advances in methods, while reinforcing the crucial role of standardization to enable comparisons between populations and over time.

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                        • Stamler, J., R. Stamler, J. D. Neaton, et al. 1999. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy. Findings for 5 large cohorts of young adult and middle-aged men and women. JAMA 282.21: 2012–2018.

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                          In contrast to studies of high CHD risk, this report reversed the question: Who is at low risk, and what are the consequences? It was among the first of such studies and is important for its new emphasis on preservation of low CHD risk from early life to middle age.

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                          • Tunstall-Pedoe, H., K. Kuulasmaa, M. Mähönen, H. Tolonen, E. Ruokokoski, and P. Amouyel. 1999. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA Project populations. Lancet 353.9164: 1547–1557.

                            DOI: 10.1016/S0140-6736(99)04021-0Save Citation »Export Citation »E-mail Citation »

                            Presents data on CHD (“IHD,” or ischemic heart disease, in this study) death rates based on ten-year surveillance of populations in thirty-nine countries, making it the giant of CVD epidemiologic studies. Changes in death rates were influenced more heavily by declining event rates, rather than survival when events occurred.

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                            • Tunstall-Pedoe, H., D. Vanuzzo, M. Hobbs, et al. 2000. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 355.9205: 688–700.

                              DOI: 10.1016/S0140-6736(99)11181-4Save Citation »Export Citation »E-mail Citation »

                              In the same study as Tunstall-Pedoe, et al. 1999, improvements in acute care for CHD cases (“coronary care”) and postevent case management (“secondary prevention”) were seen as contributing more strongly to favorable changes in event rates, case-fatality, and CHD death rates than risk factor change.

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                              • Yusuf, S., S. Hawken, S. Ôunpuu, et al. 2004. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 364.9438: 937–952.

                                DOI: 10.1016/S0140-6736(04)17018-9Save Citation »Export Citation »E-mail Citation »

                                This study comparing cases and noncases of acute coronary events in fifty-two represented countries throughout the world demonstrated the virtual universality of risk predictors throughout the world, with nine factors accounting for approximately 70 to 99 percent of risk across the countries.

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                                Stroke

                                Stallones 1965, a review of stroke epidemiology, was limited by a scarcity of data and a limitation of methods to distinguish among stroke types, but early ideas about population differences in stroke are found in this review. Thom, et al. 1992 used mortality data from Europe, North America, Australia and Japan from midcentury to the late 1980s and showed striking declines in stroke mortality in many countries. Population variation in stroke occurrence by race and ethnicity has been shown in multiple studies, such as Sacco, et al. 1998. Prospective Studies Collaboration 2002 demonstrates the power of pooling data, showing in detail the relation of blood pressure levels to stroke risk. Gorelick and Alter 2002 is a collection of reports that emphasize approaches to stroke prevention. Sarti, et al. 2003 examines factors affecting trends in stroke mortality in the subset of MONICA Project centers where stroke was studied; this report indicates some of the challenges in population studies of stroke.

                                • Gorelick, P. B., and M. Alter, eds. 2002. The prevention of stroke. Boca Raton, FL: Parthenon.

                                  DOI: 10.1201/NOE1842141151.ch10Save Citation »Export Citation »E-mail Citation »

                                  Multiple experts in epidemiology and prevention of stroke contributed chapters addressing risk factors or predictors of stroke, approaches to stroke prevention in clinical practice and public health, and issues in stroke treatment.

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                                  • Prospective Studies Collaboration. 2002. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 360.9349: 1903–1913.

                                    DOI: 10.1016/S0140-6736(02)11911-8Save Citation »Export Citation »E-mail Citation »

                                    Combining data from numerous large studies permits powerful detailed analysis of risk factor–event relationships. This report illustrates the approach to describe the relation of blood pressure in early follow-up to stroke events over ensuing years. The relation is continuous and shows no threshold level: Lower pressure means lower risk.

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                                    • Sacco, R. L., B. Boden-Albala, R. Gan, et al. 1998. Stroke incidence among white, black, and Hispanic residents of an urban community: The Northern Manhattan Stroke Study. American Journal of Epidemiology 147.3: 259–268.

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                                      Incidence of stroke can be measured in defined communities through population-based surveillance, as in NoMaSS. Rigorous comparison of event rates and outcomes between racial/ethnic groups showed that BLACKS and Hispanics experienced 2–2.5 times the stroke rate of whites, demonstrating marked disparities in this major form of CVD.

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                                      • Sarti, C., B. Stegmayr, H. Tolonen, M. Mähönen, J. Tuomilehto, and K. Asplund. 2003. Are changes in mortality from stroke caused by changes in stroke event rates or case fatality? Results from the WHO MONICA Project. Stroke 34.8: 1833–1840.

                                        DOI: 10.1161/01.STR.0000081224.15480.52Save Citation »Export Citation »E-mail Citation »

                                        To understand changing stroke death rates in the ten participating MONICA Project centers, this analysis distinguished between changing event rates and changing case fatality, finding the latter to be more important; however, improved case fatality was less clearly due to treatment than to reduced severity of cases, attributable to risk factor improvement.

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                                        • Stallones, R. A. 1965. Epidemiology of cerebrovascular disease: a review. Journal of Chronic Diseases 18.8: 859–872.

                                          DOI: 10.1016/0021-9681(65)90022-6Save Citation »Export Citation »E-mail Citation »

                                          Stroke in Western countries is more difficult to study than CHD, being several times less frequent and multifaceted, with somewhat different epidemiologic features (e.g., occlusive strokes result primarily from atherosclerosis, while hemorrhagic strokes result primarily from hypertension). Interest in Asia, where stroke predominates over CHD, led to substantial early contributions from Japan.

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                                          • Thom, T. J., F. H. Epstein, J. J. Feldman, P. E. Leaverton, and M. Wolz. 1992. Total mortality and mortality from heart disease, cancer and stroke from 1950 to 1987 in 27 countries: Highlights of trends and their interrelationships among causes of death. NIH Publication 92-3088. Bethesda, MD: National Heart, Lung, and Blood Institute.

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                                            Countries reporting reliable annual stroke death rates to WHO over nearly forty years were represented in this analysis of trends. Unlike CHD, stroke death rates and patterns were similar for men and women, declined in most countries (especially Japan), and increased uniquely in Czechoslovakia, Hungary, Poland, and Yugoslavia.

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                                            Heart Failure

                                            Gillum 1993 was among the earlier reports to address methodological issues in the use of hospital data to study the frequency of heart failure. Bumgarner and Speizer 1993 observed that one category of heart failure, affecting the right side of the heart, is due to pulmonary conditions common in developing countries due to widespread exposures. National Heart, Lung, and Blood Institute 2006 included rare estimates of incidence of heart failure based on ongoing population-based cohort studies. Schocken, et al. 2008 is a Scientific Statement from the American Heart Association (AHA) on prevention of heart failure; it illustrates the collaborative and formalized process of guideline development by this organization. A separate guideline for diagnosis and management of existing cases is illustrated by Jessup, et al. 2009.

                                            • Bumgarner, J. R., and F. E. Speizer. 1993. Chronic obstructive pulmonary disease. In Disease control priorities in developing countries. Edited by D. T. Jamison, W. H. Mosley, A. R. Measham, and J. L. Bobadilla, 595–608. Oxford: Oxford Univ. Press.

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                                              Cigarette smoking, air pollution, childhood respiratory infections, and occupational dust exposures all contribute to a particular form of heart failure, affecting the right side of the heart, especially in developing countries where such exposures are common.

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                                              • Gillum, R. F. 1993. Epidemiology of heart failure in the United States. American Heart Journal 126.4: 1042–1047.

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                                                Gillum documents the difficulty of estimating frequency of heart failure on the basis of hospitalization data, due to the discrepancy in counts when only first-listed versus all-listed diagnoses are included; US estimates were made taking this methodologic issue into account.

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                                                • Jessup, M., W. T. Abraham, D. E. Casey, et al. 2009. Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 119: 1977–2016.

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                                                  The ACCF/AHA guidelines recognize the now-prominent issue of frequent rehospitalization of patients with heart failure, with attendant risks and costs. Growing attention to this problem seeks to improve outpatient care, arrest progression to the point where readmission is required, and thereby reduce burden and costs.

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                                                  • National Heart, Lung, and Blood Institute. 2006. Incidence and prevalence: 2006 chart book on cardiovascular and lung diseases. Bethesda, MD: National Heart, Lung, and Blood Institute.

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                                                    Data from the several community-based (some multilocal) cohort studies supported by NHLBI illustrate the contribution of these studies to epidemiology of multiple cardiovascular conditions. The chart book presents findings by age, by sex, and by race over a period of twenty-five years based on these ongoing studies.

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                                                    • Schocken, D. D., E. J. Benjamin, G. C. Fonarow, et al. 2008. Prevention of heart failure: A Scientific Statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation 117: 2544–2565.

                                                      DOI: 10.1161/CIRCULATIONAHA.107.188965Save Citation »Export Citation »E-mail Citation »

                                                      Measures were advocated for prevention of heart failure that mimic those for hypertension and CHD. Consideration was also given to early (nonsymptomatic) left heart failure and the need to develop tools for its detection and means of treatment.

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                                                      The Main Determinants

                                                      Kannel, et al. 1961, a classic report from the Framingham Heart Study, introduced the term “risk factor.” Two decades later, Hopkins and Williams 1981 documented 246 risk factors for coronary heart disease (CHD) and constructed a conceptual model of their interrelations. Magnus and Beaglehole 2001 counters the misconception that the major risk factors for CHD account for no more than 50 percent of disease occurrence. Ezzati, et al. 2006, consistent with this perspective, estimates that the main determinants of ischemic heart disease and stroke worldwide account for the greater part of population risk. Stamler 2007 presents further evidence that, relative to the stratum of the US adult population at low CHD risk, those with one or more major risk factors account for far more than 50 percent of cases.

                                                      • Ezzati, M., S. Vander Hoorn, A. D. Lopez, et al. 2006. Comparative quantification of mortality and burden of disease attributable to selected risk factors. In Global burden of disease and risk factors. Edited by A. D. Lopez, C. D. Mathers, M. Ezzati, D. T. Jamison, and C. J. L. Murray, 241–396. Washington, DC: World Bank.

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                                                        Risks attributable to major risk factors account for some 90 percent of ischemic heart disease and of stroke, according to results of the Global Burden of Disease Study.

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                                                        • Hopkins, P. N., and R. R. Williams. 1981. A survey of 246 suggested coronary risk factors. Atherosclerosis 40.1: 1–52.

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                                                          Based on the criterion of one or more published reports of a statistically significant association with CHD, 246 risk factors were catalogued. A conceptual model was presented in which many of these factors were included in a sequential relation from onset of subclinical CHD to triggering of acute coronary events.

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                                                          • Kannel, W. B., T. R. Dawber, A. Kagan, et al. 1961. Factors of risk in the development of coronary heart disease—Six-year follow-up experience: The Framingham Study. Annals of Internal Medicine 55.1: 33–50.

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                                                            The term “risk factor” was introduced in this report from the Framingham Heart Study, based on the early observation that serum cholesterol concentration, blood pressure, and electrocardiographic evidence of left ventricular hypertrophy were strong predictors of later development of CHD.

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                                                            • Magnus, P., and R. Beaglehole. 2001. The real contribution of the major risk factors to the coronary epidemics: Time to end the 50% myth. Archives of Internal Medicine 161.22: 2657–2660.

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                                                              The authors sought to dispel the idea that recognized major risk factors fail to account for more than half the occurrence of CHD. That argument is cited to dissuade from clinical and population interventions based on known risk factors and to demand research to identify more potent causal factors instead.

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                                                              • Stamler, J. 2007. Low risk—and the “No more than 50%” myth/dogma. Archives of Internal Medicine 167.6: 537–538.

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                                                                Further evidence to counter the argument that current risk factors do not explain occurrence of CHD results, from taking as reference the lowest risk stratum in the population, in relation to those factors. The vast majority of events occur with one or more such factors; very few occur with none.

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                                                                Genes and Environment

                                                                An early conceptual model of the relation of genes to coronary heart disease was presented in Sing, et al. 1992. For a public health orientation to more contemporary studies of genetics of cardiovascular disease, Khoury, et al. 2004 is a valuable introductory text. Jablonka 2004 adds the dimension of epigenetic inheritance to more familiar genetic mechanisms of transmission of heritable characteristics. Davey Smith, et al. 2005 expresses reservations about overconfidence in what new significant findings genetic epidemiology will deliver in the short term. Hudson 2006 calls attention to unregulated marketing of genetic testing to the public. Arnett, et al. 2007 presents a detailed review of contributions from genetics and genomics, to that date, with interpretation of the utility of findings for practice, most favorable for family history.

                                                                • Arnett, D. K., A. E. Baird, R. A. Barkley, et al. 2007. Relevance of genetics and genomics for prevention and treatment of cardiovascular disease: A scientific statement from the American Heart Association Council on Epidemiology and Prevention, the Stroke Council, and the Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation 115.22: 2878–2901.

                                                                  DOI: 10.1161/CIRCULATIONAHA.107.183679Save Citation »Export Citation »E-mail Citation »

                                                                  Contributions to date of genetics and genomics for understanding CVD are assessed in this detailed report. Of greatest practical utility is systematic recording of family history of CVD, because close familial resemblance of risk is well established, information is easily obtained, and practical action can follow.

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                                                                  • Davey Smith, G., S. Ebrahim, S. Lewis, A. L. Hansell, L. J. Palmer, and P. R. Burton. 2005. Genetic epidemiology and public health: hope, hype, and future prospects. Lancet 366.9495: 1484–1498.

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                                                                    Caution is expressed regarding unduly high expectations for immediate public health applications from current work in genetic epidemiology.

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                                                                    • Hudson, K. L. 2006. Genetic testing oversight. Science 313.5795: 1853.

                                                                      DOI: 10.1126/science.1134996Save Citation »Export Citation »E-mail Citation »

                                                                      Genetic testing of individuals is being marketed to the public, via the Internet and otherwise, in the absence of adequate scientific oversight regarding claims for the value of such services.

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                                                                      • Jablonka, E. 2004. Epigenetic epidemiology. International Journal of Epidemiology 33.5: 929–935.

                                                                        DOI: 10.1093/ije/dyh231Save Citation »Export Citation »E-mail Citation »

                                                                        The concept of cellular, rather than genetic, mechanisms of inheritance is addressed in this report; it is suggested, for example, that the intrauterine environment might induce heritable changes in cells that could be transmitted to subsequent generations.

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                                                                        • Khoury, M. J., J. Little, and W. Burke, eds. 2004. Human genome epidemiology: A scientific foundation for using genetic information to improve health and prevent disease. Oxford: Oxford Univ. Press.

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                                                                          Genetics and genomics are presented in multiauthor chapters. From concepts and principles of population genetic studies to practical applications to public health and disease prevention, the content is clear and informative.

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                                                                          • Sing, C. F., M. B. Haviland, A. R. Templeton, K. E. Zerba, and S. L. Reilly. 1992. Biological complexity and strategies for finding DNA variations responsible for inter-individual variation in risk of a common chronic disease, coronary artery disease. Annals of Medicine 24.6: 539–547.

                                                                            DOI: 10.3109/07853899209167008Save Citation »Export Citation »E-mail Citation »

                                                                            Difficulties in the study of genetic factors for a complex chronic disease, coronary heart disease (CHD), are discussed. A graphic conceptual model depicts an array of genes, subsets interacting with distinct physiologic systems, and through these effects interacting with environmental factors and the ages of individuals to indicate the probability of a CHD event.

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                                                                            Dietary Imbalance

                                                                            National Research Council Committee on Diet and Health 1989 is a key reference point for understanding the connections between specific nutrients and chronic diseases (or noncommunicable diseases [NCDs]). An encyclopedic scholarly review, it provides a backdrop for more recent studies on any of a wide variety of issues in this arena. Stamler 1992 places nutritional contributions to epidemic coronary heart disease in context with the other major risk factors. Reddy and Katan 2004 focuses on the potential for nutritional policies and practices to impact the global burden of hypertension and cardiovascular disease. World Health Organization 2004 presents a global strategy for NCD prevention, in which diet is an essential component, setting the stage for policy and program implementation going forward. Willett, et al. 2006 addresses diet and other lifestyle changes from the perspective of global policy approaches to NCD prevention. US Department of Agriculture and US Department of Health and Human Services 2010 (Dietary Guidelines for Americans) presents the conclusions of the two US federal agencies responsible for determining dietary policy across a wide range of foods and nutrients.

                                                                            • National Research Council Committee on Diet and Health. 1989. Diet and health: Implications for reducing chronic disease risk. Washington, DC: National Academy Press.

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                                                                              This volume presents the scientific basis for nutritional recommendations regarding calories, fats and other lipids, protein, carbohydrates, dietary fiber, fat-soluble vitamins, minerals, trace elements, electrolytes, alcohol, coffee/tea/other nonnutritive dietary components, and dietary supplements. It is a rich source of objectively presented background information on each of these topics.

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                                                                              • Reddy, K. S., and M. B. Katan. 2004. Diet, nutrition and the prevention of hypertension and cardiovascular diseases. Public Health Nutrition 7.1A: 167–186.

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                                                                                Dietary factors were considered well-enough established as causes of CVD to support intervention at both individual and population levels, through coordinated action by governments, international organizations, and the food industry. Both promotion of healthy diets and discouragement of unhealthy diets were called for.

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                                                                                • Stamler, J. 1992. Established major coronary risk factors. In Coronary heart disease epidemiology: From aetiology to public health. Edited by M. Marmot and P. Elliott, 35–66. Oxford: Oxford Univ. Press.

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                                                                                  This historical account of research on causes of atherosclerosis and coronary heart disease from roughly 1900–1990 provides a succinct overview of decades of epidemiologic and other studies determining the “four established major risk factors”: cigarette smoking, total blood cholesterol, blood pressure, and (underlying the last two, among other deleterious effects) “rich” diet.

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                                                                                  • Willett, W. C., J. P. Koplan, R. Nugent, C. Dusenbury, P. Puska, and T. Gaziano. 2006. Prevention of chronic disease by means of diet and lifestyle changes. In Disease control priorities in developing countries. 2d ed. Edited by D. T. Jamison, J. G. Breman, A. R. Measham, et al., 833–850. Washington, DC: World Bank.

                                                                                    DOI: 10.1596/978-0-8213-6179-5/Chpt-44Save Citation »Export Citation »E-mail Citation »

                                                                                    Willett and others, focusing on developing countries, call for nutrition interventions in six areas: undertaking education, improving the food supply, making healthy foods more available and less costly, promoting healthy foods, limiting aggressive marketing of foods to children, and implementing supportive economic policies. Copublished with Oxford University Press.

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                                                                                    • World Health Organization. 2004. Global strategy on diet, physical activity and health. Geneva, Switzerland: World Health Organization.

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                                                                                      The WHO Global Strategy fulfilled a 2002 World Health Assembly resolution and included principles of action toward national-level changes in diet and physical activity. Strategies of member states and others were to be science-based, address noncommunicable diseases comprehensively, be undertaken in a multisectoral approach, and be consistent with other relevant principles.

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                                                                                      • US Department of Agriculture and US Department of Health and Human Services. 2010. Dietary guidelines for Americans 2010. Washington, DC: US Government Printing Office.

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                                                                                        The 2010 edition of this US publication (produced every five years) presents national dietary recommendations, “the federal government’s evidence-based nutritional guidance to promote health, reduce the risk of chronic diseases, and reduce the prevalence of overweight and obesity through improved nutrition and physical activity.”

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                                                                                        Physical Inactivity

                                                                                        Morris 1992 reviews the origins of the hypothesis that physical activity influences the risk of coronary heart disease, presented by the epidemiologist responsible for the earliest studies of this factor. Paffenbarger, et al. 1986 presents findings of strong predictive relations between levels of physical activity in early adulthood (during university attendance) and later life. Kelder, et al. 1994 presents evidence on the persistence of behavioral patterns with age, an issue of importance for strategies of prevention from early in life. National Center for Chronic Disease Prevention and Health Promotion 1996, a report of the Surgeon General on physical activity and health, coincided with the 1996 Olympics held in the United States, bringing together a historical perspective, review of relevant science, and recommendations for improving physical activity nationally. US Department of Health and Human Services 2008 (Physical Activity Guidelines for Americans) updates the 1996 report and reflects current views of means of changing activity levels. Guthold, et al. 2008 presents results of a groundbreaking survey comparing national data by means of a standardized instrument for data collection on physical activity. Lee, et al. 2012 presents a worldwide assessment of the contribution of physical inactivity to the burden of disease and life expectancy in relation to major noncommunicable diseases, including cardiovascular disease.

                                                                                        • Guthold, R., T. Ono, K. L. Strong, S. Chatterji, and A. Morabia. 2008. Worldwide variability in physical inactivity: A 51-country survey. American Journal of Preventive Medicine 34.6: 486–494.

                                                                                          DOI: 10.1016/j.amepre.2008.02.013Save Citation »Export Citation »E-mail Citation »

                                                                                          This report demonstrates application of the International Physical Activity Questionnaire (IPAQ), a validated instrument for assessing duration of vigorous, moderate, and walking activities during the seven days prior to administration. Data are presented from fifty-one predominantly low- and middle-income countries across the six WHO Regions.

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                                                                                          • Kelder, S. H., C. L. Perry, K. -I. Klepp, and L. L. Lytle. 1994. Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. American Journal of Public Health 84.7: 1121–1126.

                                                                                            DOI: 10.2105/AJPH.84.7.1121Save Citation »Export Citation »E-mail Citation »

                                                                                            This report concerns “tracking” from childhood through adolescence of coronary heart disease (CHD) risk behaviors. Persistence of physical activity patterns as well as smoking and food choices across these ages indicates the potential importance of intervention to sustain healthy behaviors from childhood, or to restore them at early ages if already unfavorable.

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                                                                                            • Lee, I.-M., E. J. Shiroma, F. Lobelo, P. Puska, S. N. Blair, and P. T. Katzmarzyk. 2012. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 380.9838: 219–229.

                                                                                              DOI: 10.1016/S0140-6736(12)61031-9Save Citation »Export Citation »E-mail Citation »

                                                                                              A report of the Lancet Physical Activity Series Working Group. This global analysis for the world, each WHO region, and each country provides estimates of prevalence of physical inactivity in persons with coronary heart disease, type 2 diabetes, breast cancer, colon cancer, and death from any cause. The evidence presented supports policies to increase daily physical activity among populations throughout the world.

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                                                                                              • Morris, J. N. 1992. Exercise versus heart attack: history of a hypothesis. In Coronary heart disease epidemiology: From aetiology to public health. Edited by Marmot M. nad Elliott P, 242–255. Oxford: Oxford Univ. Press.

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                                                                                                Within a large collection of contributed chapters, Morris provides a uniquely authoritative perspective on early development of the hypothesis that physical activity is protective against coronary heart disease (CHD). His research on differential CHD risk between London transport workers (sedentary bus drivers versus ambulatory bus conductors) and its implications are discussed.

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                                                                                                • National Center for Chronic Disease Prevention and Health Promotion. 1996. Physical activity and health: A report of the Surgeon General. Atlanta: National Center for Chronic Disease Prevention and Health Promotion.

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                                                                                                  A societal and cultural perspective on physical activity is presented, from early China and India and ancient Greece to the present. In recent decades, recognition of a population-wide lack of fitness for military service among young adults has stimulated national remedial strategies. Obesity and other health concerns are now paramount.

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                                                                                                  • Paffenbarger, R. S., Jr., R. T. Hyde, A. L. Wing, and C. C. Hsieh. 6 March 1986. Physical activity, all-cause mortality, and longevity of college alumni. New England Journal of Medicine 314.10: 605–613.

                                                                                                    DOI: 10.1056/NEJM198603063141003Save Citation »Export Citation »E-mail Citation »

                                                                                                    By use of the personal tracking system of a university alumni organization, linked with records of activity during university attendance, the investigators were able to study the relation between early and interim activity and occurrence of CHD events. The study was important for both its substantive and methodologic contributions.

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                                                                                                    • US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Atlanta: US Department of Health and Human Services.

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                                                                                                      More than thirty years and more than thirty published recommendations on physical activity culminated in this report, described as “the first comprehensive guidelines on physical activity ever to be issued by the federal government.” These and other sources recommend both goal levels of activity for individuals and population-wide policy changes.

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                                                                                                      Obesity

                                                                                                      World Health Organization 2000 recognizes the global epidemic of obesity and proposes strategies to address it from individual and population-wide approaches. Mullis, et al. 2004 notes the research needs for obesity policies and proposes areas for action and evaluation. Daniels, et al. 2005 focuses on obesity in childhood and adolescence, from questions about causation to clinical approaches to treatment. Koplan, et al. 2005, an Institute of Medicine (IOM) report, gives prominent attention to this major health issue for the United States. The global prevalence of obesity by world economic region, and by sex, is presented in Yach, et al. 2006. The Sydney Principles support the recommendation of the WHO Global Strategy (see World Health Organization 2004, cited under Dietary Imbalance) on the marketing of food products to children. Labarthe, et al. 2009 shows that measures of body mass and composition beyond body mass index (BMI) alone are important for understanding the development and consequences of overweight and obesity in childhood and adolescence.

                                                                                                      • Daniels, S. R., D. K. Arnett, R. H. Eckel, et al. 2005. Overweight in children and adolescents: Pathophysiology, consequences, prevention, and treatment. Circulation 111: 1999–2012.

                                                                                                        DOI: 10.1161/01.CIR.0000161369.71722.10Save Citation »Export Citation »E-mail Citation »

                                                                                                        This analysis points to a general lack of longitudinal, prospective data on incidence of childhood obesity, that is, on precursors of change from normal to overweight or obese. Attention is called to potential “vulnerable,” “critical,” or “sensitive” periods of development important for causation or prevention of childhood obesity.

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                                                                                                        • Koplan, J. P., C. T. Liverman, V.I. Kraak, eds. 2005. Preventing childhood obesity: Health in the balance. Washington, DC: National Academies Press.

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                                                                                                          This report concludes that this serious problem requires urgent action; both physical and emotional health are at issue; population-based approaches are needed to reach all children; diet and physical activity are essential components of intervention, with a goal of energy balance; and individual and societal changes alike are needed.

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                                                                                                          • Labarthe, D. R., S. Dai, R. S. Day, J. E. Fulton, and J. A. Grunbaum. 2009. Findings from Project HeartBeat! Their importance for CVD prevention. American Journal of Preventive Medicine 37.1: S105–S115.

                                                                                                            DOI: 10.1016/j.amepre.2009.04.013Save Citation »Export Citation »E-mail Citation »

                                                                                                            Indicators of body mass and composition other than BMI (e.g., lean versus fat mass, waist circumference, skinfold measurements, percent body fat) reveal important variations through childhood and adolescence, as well as differences in relationships to major CVD risk factors, especially blood lipids and blood pressure.

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                                                                                                            • Mullis, R. M., S. N. Blair, L. J. Aronne, et al. 2004. Prevention Conference VII: Obesity, a Worldwide Epidemic Related to Heart Disease and Stroke; Group IV: Prevention/Treatment. Circulation 110:e484–e488.

                                                                                                              DOI: 10.1161/01.CIR.0000140072.49273.6BSave Citation »Export Citation »E-mail Citation »

                                                                                                              Research is called for regarding the effectiveness of broad-based policies for obesity prevention, and for developing and evaluating such policies through their implementation. Policy areas to be included would be physical and social environmental change, financial incentives and taxation, delivery of health care, and specific attention to schools and worksites.

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                                                                                                              • The Sydney Principles.

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                                                                                                                Marketing of food products to children, one of the topics addressed by WHO’s Global Strategy (see World Health Organization 2004, cited under Dietary Imbalance), is the focus of the Sydney Principles adopted by the International Obesity Taskforce in April 2007. The target is to counter the widespread marketing of unhealthy foods—energy-dense and nutrient-poor—especially to children.

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                                                                                                                • World Health Organization. 2000. Obesity: Preventing and managing the global epidemic. WHO Technical Report 894. Geneva, Switzerland: World Health Organization.

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                                                                                                                  “Universal prevention” is proposed to address obesity, with a focus on the total population, beyond individual-level screening and case identification. “Selective prevention” would apply to groups considered at high risk of obesity by virtue of demographic or other characteristics. “Targeted prevention” would apply to individuals at particularly high risk. Summary available online.

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                                                                                                                  • Yach, D., D. Stuckler, and K. D. Brownell. 2006. Epidemiologic and economic consequences of the global epidemics of obesity and diabetes. Nature Medicine 12.1: 62–66.

                                                                                                                    DOI: 10.1038/nm0106-62Save Citation »Export Citation »E-mail Citation »

                                                                                                                    Prevalence of obesity is estimated by economic region of the world and for eleven of the largest countries, then projected from 2002 levels to 2010. Highest prevalence and greatest predicted increases are in high- and upper-middle-income regions; female dominance is greatest in low-income areas.

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                                                                                                                    Adverse Blood Lipid Profile

                                                                                                                    Keys 1983, an early autobiographical account, describes the origins of what was to become the “diet-heart hypothesis,” in which blood lipids play the intermediary role between the fat composition of the diet and development of coronary heart disease and other atherosclerotic conditions. Brown and Goldstein 1996, by Nobel laureates (for work on lipid transport in relation to atherogenesis), forecasted that heart attacks as a public health problem would become history early in the new century. National Heart, Lung, and Blood Institute 2002, a report from an expert panel, illustrates a highly elaborated guideline for clinical and public health practice, specific to cholesterol. Cholesterol Treatment Trialists’ Collaborators 2005 demonstrates—through meta-analysis of fourteen trials—important outcomes that could not be studied in the individual trials alone. World Health Organization 2007 presents guidelines for cardiovascular risk assessment and management that closely parallel those for Europe but differ in their approach to targets of cholesterol lowering. National Heart, Lung, and Blood Institute 2011, a report on cardiovascular health and risk reduction in children and adolescents, illustrates recent progress toward synthesis of related guidelines into a single coherent document.

                                                                                                                    High Blood Pressure

                                                                                                                    MacMahon, et al. 1990 contributes importantly to assessment of risk associated with highly variable personal characteristics, such as blood pressure, showing that single-occasion baseline measurements are inadequate for this purpose. INTERSALT Co-operative Research Group 1986 describes the group’s major international collaborative investigation of the relation between dietary sodium intake and blood pressure, especially the age-related increase as it varies among populations. Kearney, et al. 2005 demonstrates the global dimension of hypertension and the massive public health burden it represents. Fahey, et al. 2006 reports on a Cochrane analysis for randomized trials of hypertension management to consider what features most consistently predict favorable outcomes. World Health Organization 2007 weighs evidence for sodium reduction as a population-wide strategy for reducing the burden of hypertension worldwide, and presents policy recommendations accordingly. Though there are some controversies in this area, referenced in this source, the WHO recommendations reflect a widely held consensus on the need for public health action on sodium reduction. Asaria, et al. 2007 utilizes WHO methodology for policy evaluation and finds sodium reduction to have the greatest potential impact on deaths due to noncommunicable diseases in low- and middle-income countries. Institute of Medicine 2010, a report on means of improving hypertension control through improved management, calls for changes in health systems to achieve this goal. Centers for Disease Control and Prevention 2011 illustrates the use of national probability sample data in two time periods to show that the United States is far behind its goals for hypertension awareness, treatment, and control.

                                                                                                                    • Asaria, P., D. Chisholm, C. Mathers, M. Ezzati, and R. Beaglehole. 2007. Chronic disease prevention: Health effects and financial costs of strategies to reduce salt intake and control tobacco abuse. Lancet 370.9604: 2044–2053.

                                                                                                                      DOI: 10.1016/S0140-6736(07)61698-5Save Citation »Export Citation »E-mail Citation »

                                                                                                                      Using WHO methodology for policy analysis, the authors found that for twenty-three low- and middle-income countries experiencing 80 percent of noncommunicable disease (NCD) deaths, reductions in average population sodium intake have the greatest impact—in ten years, preventing 8.5 million deaths by a 15 percent reduction, and 28 million deaths by reduction to <5g/day.

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                                                                                                                      • Centers for Disease Control and Prevention. 1 February 2011. Vital signs: Prevalence, treatment, and control of hypertension—United States, 1999–2002 and 2005–2008. Morbidity and Mortality Weekly Report 60.4: 1–6.

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                                                                                                                        The high prevalence of hypertension in the United States, by age, sex, and race/ethnicity, is documented, as is the shortfall in awareness, treatment, and control of this condition.

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                                                                                                                        • Fahey, T., K. Schroeder, and S. Ebrahim. October 2006. Interventions used to control blood pressure in patients with hypertension. Cochrane Database of Systematic Reviews18.4: CD005182.

                                                                                                                          DOI: 10.1002/14651858Save Citation »Export Citation »E-mail Citation »

                                                                                                                          A Cochrane review of fifty-six randomized trials of various hypertension control methods finds a US multicenter, population-based trial, the Hypertension Detection and Follow-up Program in the 1970s, showing that an organized system of care and strictly increasing intensity of treatment to achieve goal blood pressure was most clearly effective.

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                                                                                                                          • INTERSALT Co-Operative Research Group. 1986. INTERSALT Study: An international co-operative study on the relation of blood pressure to electrolyte excretion in populations, I: Design and methods. Hypertension 4.6: 781–787.

                                                                                                                            DOI: 10.1097/00004872-198612000-00014Save Citation »Export Citation »E-mail Citation »

                                                                                                                            The INTERSALT Study of the 1980s of fifty-two population samples in thirty-two countries was undertaken to investigate the relation between habitual sodium intake, measured by 24-hour urine collections, and the age-related increase in systolic and diastolic blood pressure. The details of the rigorous design and methods are described here.

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                                                                                                                            • Institute of Medicine. 2010. A population-based policy and systems change approach to prevent and control hypertension. Washington, DC: National Academies Press.

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                                                                                                                              This IOM report finds hypertension a neglected disease, and presents evidence in support of numerous recommendations for action to prevent hypertension and improve its control. Only a minority of persons with hypertension in the United States have it controlled, despite longstanding availability of effective medications.

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                                                                                                                              • Kearney, P. M., M. Whelton, K. Reynolds, P. K. Muntner, and J. He. 2005. Global burden of hypertension: analysis of worldwide data. Lancet 365.9455: 217–223.

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                                                                                                                                Prevalence of hypertension among adults age twenty and older is estimated for the year 2000 and projected to 2025, worldwide and for World Bank regions. Overall, 26 percent of adults were estimated to have hypertension in 2000, with projected growth in numbers from 972 million to 1.56 billion in 2025.

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                                                                                                                                • MacMahon, S., R. Peto, J. Cutler, R. Collins, P. Sorlie, J. Neaton, R. Abbott, J. Godwin, A. Dyer, and J. Stamler. 1990. Blood pressure, stroke, and coronary heart disease: Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 335.8692: 765–774.

                                                                                                                                  DOI: 10.1016/0140-6736(90)90878-9Save Citation »Export Citation »E-mail Citation »

                                                                                                                                  This groundbreaking methodologic paper highlighted that the standard way of assessing the epidemiologic risk associated with elevated blood pressure substantially underestimated its impact. Multiple blood pressure measurements are needed over time to assess and manage this condition adequately. The principles illustrated here apply to other factors with high intra-individual variability.

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                                                                                                                                  • World Health Organization. 2007. Reducing salt intake in populations: Report of a WHO forum and technical meeting, 5–7 October 2006, Paris, France. Geneva, Switzerland: World Health Organization.

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                                                                                                                                    The potential for reduction of population-wide sodium intake to have a major global impact on hypertension and its attendant morbidity, mortality, and economic losses is the focus of this WHO-sponsored report. The scientific background and concluding recommendations provide a platform for action by WHO and other global entities.

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                                                                                                                                    Diabetes

                                                                                                                                    Reaven 1988 described what has come to be known as “the metabolic syndrome,” a group of factors related to diabetes, on the one hand, and risk of cardiovascular disease (CVD) on the other, and now a prominent focus of research. King, et al. 1995 provides references to materials enabling others to take programmatic action to implement previously developed recommendations for diabetes prevention and control. Bao, et al. 1996 shows the importance of high insulin concentrations, one component of the metabolic syndrome, in predicting increased CVD risk factors in childhood and adolescence. Ford, et al. 2002 demonstrates the use of data from the Third National Health and Nutrition Examination Survey (1988–1994) in the United States to examine issues in prevalence of the metabolic syndrome. Narayan, et al. 2006 presents data on global aspects of diabetes, especially in developing countries. Task Force on Diabetes and Cardiovascular Diseases 2007, a report from two European groups, indicates collaboration to provide coherent practice guidelines for diabetes management in Europe. Narayan, et al. 2011, on public health perspectives on diabetes, provides an extensive review of the field.

                                                                                                                                    • Bao, W., S. R. Srinivasan, and G. S. Berenson. 1996. Persistent elevation of plasma insulin levels is associated with increased cardiovascular risk in children and young adults: the Bogalusa Heart Study. Circulation 93:54–59.

                                                                                                                                      DOI: 10.1161/01.CIR.93.1.54Save Citation »Export Citation »E-mail Citation »

                                                                                                                                      Data from the Bogalusa Heart Study in school-age children, with follow-up to early adulthood, demonstrate that elevated insulin concentrations are associated with obesity, hypertension, and adverse blood lipid profiles. Thus, insulin levels appear implicated in the set of conditions contributing to early development of CVD risk.

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                                                                                                                                      • Ford, E. S., W. H. Giles, and W. H. Dietz. 2002. Prevalence of the metabolic syndrome among US adults. Findings from the Third National Health and Nutrition Examination Survey. JAMA 287.3: 356–359.

                                                                                                                                        DOI: 10.1001/jama.287.3.356Save Citation »Export Citation »E-mail Citation »

                                                                                                                                        Data from this probability sample of the US population are used to estimate the prevalence of the metabolic syndrome in population strata defined by age, sex, or race/ethnicity. Variation in prevalence includes striking differences among demographic groups in the proportions of “cases” accounted for by different components of the syndrome.

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                                                                                                                                        • King, H., W. Gruber, and T. Lander, eds. 1995. Implementing national diabetes programmes: Report of a WHO meeting. Geneva, Switzerland: World Health Organization, Division of Noncommunicable Diseases.

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                                                                                                                                          Presents recommendations for programs to address diabetes globally, and gives citations to supporting materials such as manuals and program guides. The intent is to provide tools through which to implement previously developed guidelines.

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                                                                                                                                          • Narayan, K. M. V., D. Williams, E. W. Gregg, and C. C. Cowie. 2011. Diabetes public health: From data to policy. New York: Oxford Univ. Press.

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                                                                                                                                            This comprehensive and authoritative text discusses current views of diabetes in the United States and developing countries, epidemiology and risk factors for complications, prevention of diabetes and its complications, control programs and policies, and emerging issues and science.

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                                                                                                                                            • Narayan, K. M. V., P. Zhang, A. M. Kanaya, et al. 2006. Diabetes: The pandemic and potential solutions. In Disease control priorities in developing countries. 2d ed. Edited by D. T. Jamison, J. G. Breman, A. R. Measham, et al., 591–603. Washington, DC: World Bank.

                                                                                                                                              DOI: 10.1596/978-0-8213-6179-5/Chpt-30Save Citation »Export Citation »E-mail Citation »

                                                                                                                                              The global dimensions of the diabetes pandemic are demonstrated, with special emphasis on developing countries, where the burden is especially great. Prevalence is estimated at 5.1 percent in 2003 and projected to increase to 6.3 percent worldwide by 2025. Copublished with Oxford University Press.

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                                                                                                                                              • Reaven, G. M. 1988. Banting Lecture 1988: Role of insulin resistance in human disease. Diabetes 37.12: 1595–1607.

                                                                                                                                                DOI: 10.2337/diabetes.37.12.1595Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                In his Banting Lecture in 1988, Reaven described as “Syndrome X” a constellation of factors: insulin resistance, glucose intolerance, increased triglyceride and decreased HDL-cholesterol concentrations, and hypertension. Since grouped variously in definitions of “metabolic syndrome,” they now commonly include obesity as well. Debate continues as to whether this is a true syndrome.

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                                                                                                                                                • Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). 2007. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: Full text. European Heart Journal Supplements 9: C1–C74.

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                                                                                                                                                  Practice guidelines for management of diabetes are illustrated by those from the Task Force on Diabetes and Cardiovascular Diseases prepared in Europe. Emphasis on the relation between diabetes and CVD—which is the leading cause of death among diabetics—is a recent development with important implications for case management.

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                                                                                                                                                  Tobacco

                                                                                                                                                  US Department of Health, Education and Welfare 1964, the US Surgeon General’s Report on Smoking and Health (as it is usually described), with its assessment of tobacco smoke exposure and health, is a common point of reference regarding the causal interpretation of associations in epidemiologic studies. World Health Organization 2003, the WHO Framework Convention on Tobacco Control (FCTC), gives great impetus to tobacco control efforts throughout the world. Doll, et al. 2004 updates thirty- and forty-year follow-ups of the British Doctors Study to fifty years, providing an exceptional depth of information on the long-term consequences of smoking. US Department of Health and Human Services 2006, another Surgeon General’s report, takes the tobacco issue beyond smokers’ health to address involuntary exposure to tobacco smoke, also termed “second-hand smoke,” “environmental tobacco smoke,” or “passive smoking.” The finding that significant health risks attach to this form of tobacco smoke exposure underlies strengthened policies for smoke-free air in workplaces, public areas, and other places. Centers for Disease Control and Prevention 2007 details how US states can best utilize tobacco tax revenues to support tobacco control activities. World Health Organization 2008 provides an update on activities pursuant to the FCTC and introduces MPOWER, the Bloomberg initiative in support of the FCTC. Glantz 2008 summarizes data from eight studies in which the impact of smoke-free air regulation was evaluated. The 2012 Special issue of Tobacco Control celebrates the 20th anniversary of this publication with an extensive collection of reports on work in this field.

                                                                                                                                                  • Centers for Disease Control and Prevention. 2007. Best practices for comprehensive tobacco control programs—2007. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

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                                                                                                                                                    Based on successful US tobacco control programs, especially those in California and Massachusetts, the CDC provides guidance on effective strategies and approaches to be undertaken by states, and shows that state revenues from tobacco taxes substantially exceed the needed investment to carry out these recommendations.

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                                                                                                                                                    • Doll, R., R. Peto, J. Boreham, and I. Sutherland. 2004. Mortality in relation to smoking: 50 years’ observations on male British doctors. British Medical Journal 328:1519.

                                                                                                                                                      DOI: 10.1136/bmj.38142.554479Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                      This report presents the longest-term follow-up of the landmark study of smoking among British doctors. It demonstrates that health effects are underestimated in the absence of follow-up extending over the lifespan of the study cohort. At fifty years, one-half to two-thirds of deaths were due to smoking, largely from CVD.

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                                                                                                                                                      • Glantz, S.A. 2008. Meta-analysis of the effects of smokefree laws on acute myocardial infarction: An update. Preventive Medicine. 47.4: 452–453.

                                                                                                                                                        DOI: 10.1016/j.ypmed.2008.06.007Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                        Several studies have evaluated the impact of smoke-free laws by review of hospitalizations for acute coronary events in the affected areas. Significant and rapid declines in hospital admission followed implementation of such policies at local levels in the United States, Canada, and Italy; in New York State; and in Ireland.

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                                                                                                                                                        • Special issue: 20th Anniversary Issue. 2012. Tobacco Control 21.2.

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                                                                                                                                                          On its twentieth anniversary, Tobacco Control compiles numerous reports from prominent contributors to the field. Retrospective assessment of progress over these twenty years, lessons learned, and continuing challenges are addressed. Efforts in tobacco control and NCD prevention and control are contrasted, with implications for future work in both areas.

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                                                                                                                                                          • US Department of Health, Education, and Welfare. 1964. Smoking and health: Report of the Advisory Committee to the Surgeon General. Public Health Service Publication 1103. Washington, DC: US Department of Health, Education, and Welfare, Public Health Service.

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                                                                                                                                                            This report declared cigarette smoking a cause of lung cancer. The conclusion was based on a formal analysis of a large body of research, including associations found in multiple observational epidemiologic studies. A key contribution was the explicit application of “criteria for judgment” to evaluate the causal significance of such associations.

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                                                                                                                                                            • US Department of Health and Human Services. 2006. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

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                                                                                                                                                              Evidence of health risks to nonsmokers from secondhand exposure to tobacco smoke is reviewed here, with the conclusion that this widespread exposure causes death and disease in children and adults who do not smoke. In addition, it results in immediate adverse effects on the cardiovascular system.

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                                                                                                                                                              • World Health Organization. 2003. WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                The FCTC is the first global treaty on health established by the WHO and is intended to reduce both supply and demand for tobacco products, thereby impacting the global tobacco epidemic. Provisions regarding governmental policies, legal remedies, scientific collaboration, and institutional arrangements and financing are included, with 168 signatories presently.

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                                                                                                                                                                • World Health Organization. 2008. WHO report on the global tobacco epidemic, 2008: The MPOWER package. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                  This report presents MPOWER, a six-part policy package for countries to support implementation of the WHO Framework Convention on Tobacco Control (FCTC): “Monitor tobacco use and policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; Raise taxes on tobacco.”

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                                                                                                                                                                  Other Factors

                                                                                                                                                                  Pearson, et al. 1997 provides an overview of studies to date on hemostatic factors and cardiovascular disease (CVD), and presents a model to link multiple candidate factors with CVD outcomes. Hemingway and Marmot 1999 is a review of psychosocial factors and coronary heart disease (CHD), based on prospective epidemiologic studies, with mixed though frequently positive findings. Brook, et al. 2004 reviews evidence of association between particulate (PM2.5, fine particles) air pollution and CHD events, concluding that this is a well-documented and biologically plausible relationship of significance for public health. World Health Organization, Commission on Social Determinants of Health 2008 addresses social determinants of health and their importance in efforts to achieve the world health goal of health equity. Though not specific to CVD, the implications regarding disparities in CVD occurrence among and within countries are clearly evident. Bhattarchayya and Steptoe 2007 reviews the topic of triggers of acute coronary events, including results of epidemiologic studies and a conceptual model of mechanisms. Rehm, et al. 2009 adds to an understanding of the role of alcohol in global health in terms of the medical conditions to which it contributes and the resulting economic burden. Hlatky, et al. 2009 discusses how best to evaluate the contribution of newly identified factors to risk prediction of CVD events, a topic of continuing discussion and methodologic development. Melander, et al. 2009 complements the latter study with a practical illustration of challenges in this area of research.

                                                                                                                                                                  • Bhattarchayya, M. R., and A. Steptoe. 2007. Emotional triggers of acute coronary syndromes: Strength of evidence, biological processes, and clinical implications. Progress in Cardiovascular Diseases 49.5: 353–365.

                                                                                                                                                                    DOI: 10.1016/j.pcad.2006.11.002Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                    Triggers of acute coronary events can be studied epidemiologically through creative designs to compare life situations and experiences in fixed time intervals preceding events, with comparison over corresponding time intervals between cases and controls. Pathways through physiological responses and pathophysiological effects are hypothesized and presented in a conceptual model.

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                                                                                                                                                                    • Brook, R. D., B. Franklin, W. Cascio, et al. 2004. Air pollution and cardiovascular disease: A statement for healthcare professionals from the Expert Panel on Population and Prevention Science of the American Heart Association. Circulation 109.21: 2655–2671.

                                                                                                                                                                      DOI: 10.1161/01.CIR.0000128587.30041.C8Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                      Appreciation of the adverse cardiovascular effects of particulate air pollution has increased greatly in recent years, as reviewed in this AHA report. A model of possible biological mechanisms for this relation is presented, including links to progression of atherosclerosis, promotion of plaque rupture, and thrombosis.

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                                                                                                                                                                      • Hemingway, H., and M. Marmot. 1999. Psychosocial factors in the aetiology and prognosis of coronary heart disease: Systematic review of prospective cohort studies. BMJ 318.7196: 1460–1467.

                                                                                                                                                                        DOI: 10.1136/bmj.318.7196.1460Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                        This review of prospective studies of psychosocial factors and coronary heart disease distinguishes among psychological traits, psychological states, psychological interaction with the organization of work, and social networks and social support. Findings are mixed in each area, with some moderate or strong associations among them.

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                                                                                                                                                                        • Hlatky, M. A., P. Greenland, D. K. Arnett, et al. 2009. Criteria for evaluation of novel markers of cardiovascular risk: A scientific statement from the American Heart Association. Circulation 119.17: 2408–2416.

                                                                                                                                                                          DOI: 10.1161/CIRCULATIONAHA.109.192278Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                          While public health is chiefly concerned with the application of knowledge of established major CVD risk factors, research continues to seek new markers of risk. This report addresses methods by which to determine whether predictive relationships between newly identified markers and disease outcomes provide improved prediction over those already in use. 

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                                                                                                                                                                          • Melander, O., C. Newton-Cheh, P. Almgren, et al. 2009. Novel and conventional biomarkers for prediction of incident cardiovascular events in the community. JAMA 302.1: 49–57.

                                                                                                                                                                            DOI: 10.1001/jama.2009.943Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                            This paper provides an empirical approach to recommendations in the preceding selection (Hlatky, et al. 2009) and demonstrates that although a novel biomarker may show statistical improvement in prediction, this may offer little incremental value over assessments using traditional risk factors. This topic is receiving considerable attention in the arena of novel risk markers.

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                                                                                                                                                                            • Pearson, T. A., J. LaCava, and H. F. C. Weil. May 1997. Epidemiology of thrombotic-hemostatic factors and their associations with cardiovascular disease. American Journal of Clinical Nutrition 65.5: 1674S–1682S.

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                                                                                                                                                                              Early epidemiologic investigations of hemostatic factors and cardiovascular disease are critically appraised. A model is proposed to include both fibrinolysis and coagulation factors, whose state of balance is described as the “thrombotic predisposition.” The connection of these factors with plaque fissuring, precipitating acute coronary events, is also discussed.

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                                                                                                                                                                              • Rehm, J., C. Mathers, S. Popova, M. Thavorncharoensap, Y. Teerawattananon, and J. Patra. 2009. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 373.9682: 2223–2233.

                                                                                                                                                                                DOI: 10.1016/S0140-6736(09)60746-7Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                As part of a series of articles on the global impact of alcohol on health, Lancet in 2009 included this report on economic aspects of its use. A wide range of medical conditions and a significant contribution to the global burden of disease are attributable to alcohol use.

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                                                                                                                                                                                • World Health Organization Commission on Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                                  Global concern about the determinants of health which are most deeply rooted in social and economic structures of societies led to the WHO Commission on Social Determinants of Health and its report. Its relevance includes but extends well beyond CVD, in addressing health equity as a global health goal.

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                                                                                                                                                                                  Concepts of Causation

                                                                                                                                                                                  The editor of the British Medical Journal in 1909 reported on views of causation of arteriosclerosis presented by Sir William Osler more than one hundred years ago (see Arterio-sclerosis); parallels and divergences between these and current views are of interest. White, et al. 1959, written by leaders of American cardiology, outlined a half-century ago the factors mainly considered today as causes of heart attacks and strokes; much was known at that time on the basis of studies published in the 1940s and 1950s. Hill 1965 is among the most widely cited references on causal analysis of epidemiologic data, and Hill deserves credit for this contribution, although its traceable sources, including the 1964 report to the US Surgeon General (US Department of Health, Education and Welfare 1964, cited under Tobacco) on smoking and health are curiously not acknowledged. Among Susser’s several contributions to the literature on causal interpretation of epidemiologic evidence, Susser 1973 was the foundation, and it is widely recognized in the field. Stallones 1980 presented two views of causation, one theoretical and one practical, in an essay on the potential contributions of epidemiology in relation to the other health sciences. Stamler, et al. 2005, drawing in part on the exceptionally large database from the Multiple Risk Factor Intervention Trial (MRFIT) screening examinations and follow-up, updates evidence for “six major established risk factors” and the greatly reduced coronary heart disease mortality for those at low risk in adulthood. Rothman and Greenland 2005 expands the discussion of Rothman’s prior “component causes” concept, offering an interpretation of variation in combinations of factors associated with a particular disease. Labarthe 2011 presents a discussion of implications of causal interpretation for theory and practice in cardiovascular disease epidemiology and prevention.

                                                                                                                                                                                  • Arterio-sclerosis. 1909. British Medical Journal 2.2556: 1800.

                                                                                                                                                                                    DOI: 10.1136/bmj.2.2556.1800Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                    A century ago the British Medical Journal reported on Sir William Osler’s address under this title. His topic was causation of atherosclerosis. It is instructive to review this assessment, in which Osler reduced sixty-two theories to three main factors: “time, tension, and toxins,” with some parallels to modern theory.

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                                                                                                                                                                                    • Hill, A. B. 1965. The environment and disease: Association or causation? Proceedings of the Royal Society of Medicine 58.5: 295–300.

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                                                                                                                                                                                      Hill’s paper followed the 1964 report of the US Surgeon General (US Department of Health, Education and Welfare 1964, cited under Tobacco), included its five “criteria” for causation, and added four further elements (Hill designated the nine “considerations”). While philosophical argument continues regarding the epistemological foundations of causal analysis, these elements are nonetheless widely used in practice.

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                                                                                                                                                                                      • Labarthe, D. R.. 2011. What causes cardiovascular diseases? In Epidemiology and prevention of cardiovascular diseases: A global challenge. 2d ed. By D. R. Labarthe, 535–550. Sudbury, MA: Jones and Bartlett.

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                                                                                                                                                                                        This chapter on the evolution of causal thinking and its application to causation of cardiovascular disease places the foregoing selections and others in the context of Stallones’ dual view of causation (Stallones 1980): theoretical beauty of the comprehensive view, and practical utility of the “established major factors.” These views need not conflict.

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                                                                                                                                                                                        • Rothman, K. J., and S. Greenland. 2005. Causation and causal inference in epidemiology. American Journal of Public Health 95.1: S144–S150.

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                                                                                                                                                                                          Rothman and Greenland elaborate on Rothman’s 1976 term “component causes” (factors associated with disease and occuring in various combinations). Combinations that are “sufficient” to produce disease do so and need not be identical. Factors found in every sufficient combination may be “necessary.” The graphic representation is their “causal pie model.”

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                                                                                                                                                                                          • Stallones, R. A. 1980. To advance epidemiology. Annual Review of Public Health 1:69–82.

                                                                                                                                                                                            DOI: 10.1146/annurev.pu.01.050180.000441Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                            Stallones proposes a dual view of causes of disease. From one perspective (theory), evidence from all relevant disciplines combines to constitute “an n-dimensional matrix” in which all interrelations are connected; from the other (practice), a “directed pathway” is selected for its utility, including only very few actionable factors.

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                                                                                                                                                                                            • Stamler, J., J. D. Neaton, D. B. Garside, and M. L. Daviglus. 2005. Current status: six established major risk factors – and low risk. In Coronary Heart Disease Epidemiology from Aetiology to Public Health. 2d ed. Edited by M. Marmot and P. Elliott, 32–70. Oxford: Oxford Univ. Press.

                                                                                                                                                                                              DOI: 10.1093/acprof:oso/9780198525738.001.0001Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                              Stamler and others update his contribution to the 1992 edition and incorporate six factors: adverse diet, diet-related above-optimal levels of serum total cholesterol (TC), blood pressure (BP), overweight/obesity, diabetes mellitus (DM), and cigarette smoking.” The concept of “low risk,” at desirable levels of each of these factors, is emphasized.

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                                                                                                                                                                                              • Susser, M. 1973. Causal Thinking in the Health Sciences: Concepts and Strategies in Epidemiology. New York: Oxford Univ. Press.

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                                                                                                                                                                                                Susser’s Causal Thinking is a classic presentation of the logic and method of causal inference in epidemiology, a decade following the Surgeon General’s 1964 report on smoking and health (US Department of Health, Education and Welfare 1964, cited under Tobacco). It serves as a primer for this topic and is widely cited in the epidemiologic literature.

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                                                                                                                                                                                                • White, P. D., I. S. Wright, H. B. Sprague, et al. 1959. A Statement on Arteriosclerosis: Main cause of “heart attacks” and “strokes.” New York: National Health Education Committee.

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                                                                                                                                                                                                  Commissioned by philanthropist Mary Lasker, US cardiologists compiled in 1959 a set of recommendations for physicians and their patients to reduce the chance of “heart attacks” or “strokes” (terms still presented in quotation marks at that time). The targets: overweight, elevated cholesterol and blood pressure, excessive cigarette smoking, and heredity.

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                                                                                                                                                                                                  Strategies of Prevention

                                                                                                                                                                                                  The introduction and original meaning of the concept of “primordial prevention,” introduced in Strasser 1978, may be unknown to readers limited to the more familiar journals dealing with cardiovascular disease (CVD); however, its importance to contemporary thinking about CVD prevention policy fully justifies inclusion in this bibliography. The classic articulation of the dual “high-risk” and “population-wide” strategies of CVD prevention is presented in Rose 1981. Extending CVD prevention from adulthood to the beginnings of atherosclerosis and hypertension in childhood and youth, World Health Organization 1990 reviews the evidence and presents recommendations for global action. Dahlgren and Whitehead 1991 contributes to intervention policy the “social-ecological model,” which recognizes multiple levels of influence on individual health and disease. Stamler, et al. 1999 demonstrates the prognostic importance of low levels of the major CVD risk factors; this article stimulated a subsequent body of work that compels greater attention to preservation or restoration of low risk from early in life. Gaziano, et al. 2006 discusses a typology of health policies and intervention strategies in the context of disease control priorities for developing countries; these views are directly applicable to CVD prevention, as well as prevention efforts for other conditions. (See also World Health Organization 2007 under Adverse Blood Lipid Profile)

                                                                                                                                                                                                  • Dahlgren, G., and M. Whitehead. 1991. Policies and strategies to promote social equity in health. Stockholm: Institute for Futures Studies.

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                                                                                                                                                                                                    A hierarchical, multilevel concept of influences on health and behavior, the “social-ecological framework,” is introduced in this report. The concept is frequently invoked in discussions of policies for CVD prevention, where individual action is seen as determined by family, community, and societal factors that require concurrent policy consideration. Updated version available online.

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                                                                                                                                                                                                    • Gaziano, T., D. T. Jamison, and S. Shahid-Salles. 2006. Annex 2.A: Intervention categories and pertinent policy instruments. In Disease Control Priorities in Developing Countries. 2d ed. Edited by D. T. Jamison, J. G. Breman, A. R. Measham, et al., 59. Washington, DC: World Bank.

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                                                                                                                                                                                                      Congruence of policy types between CVD prevention and other priorities for developing countries is apparent in this presentation, which contributes to understanding the policy development process. Policy instruments are seen as tools for governments or other entities to encourage or discourage interventions across a spectrum from prevention to palliation. Copublished with Oxford University Press.

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                                                                                                                                                                                                      • Rose, G. 1981. Strategy of prevention: Lessons from cardiovascular disease. British Medical Journal 282.6279: 1847–1851.

                                                                                                                                                                                                        DOI: 10.1136/bmj.282.6279.1847Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                        Rose articulates the classic distinction between two complementary strategies of CVD prevention: the “high-risk” strategy, which addresses individuals at the extreme of a risk distribution (e.g., highest levels of cholesterol), and the “population-wide” (or “mass”) strategy, which addresses elevated risk across all but the lowest stratum of the distribution.

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                                                                                                                                                                                                        • Stamler, J., S. Stamler, J. D. Neaton, et al. 1999. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: Findings for 5 large cohorts of young adult and middle-aged men and women. JAMA 282: 2012–2018.

                                                                                                                                                                                                          DOI: 10.1001/jama.282.21.2012Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                          Long-term follow-up of large study cohorts permits examination of outcomes among persons with the most favorable levels of the major risk factors, in middle age or beyond. “Low risk,” defined in terms of these factors, means longer, healthier lives and lower health care costs, shown in this and subsequent studies.

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                                                                                                                                                                                                          • Strasser, T. 1978. Reflections on cardiovascular diseases. Interdisciplinary Science Reviews 3.3: 225–230.

                                                                                                                                                                                                            DOI: 10.1179/030801878791925921Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                            Prof. Toma Strasser of the WHO CVD Unit introduces “primordial prevention,” a strategy to avert epidemic CVD in much of the world by protecting whole societies from epidemics of the risk factors themselves. Though the term has gradually become widely accepted, its realization in policy and practice has lagged.

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                                                                                                                                                                                                            • World Health Organization. 1990. Prevention in childhood and youth of adult cardiovascular diseases: Time for action. Technical Report 792. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                                                              This WHO report calls for global attention to the need and opportunity to apply preventive strategies at these early ages. It is recommended that all member states develop policies and programs to improve nutrition, increase physical activity, and eliminate tobacco use among children and youth, to prevent adult CVD.

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                                                                                                                                                                                                              Evidence, Recommendations, Guidelines, and Policies

                                                                                                                                                                                                              World Health Organization 1957 reports on a 1955 meeting that recognized the global reach of epidemic cardiovascular disease (CVD) and a dearth of evidence on which to base intervention policies or recommendations. A research agenda was presented to close this gap. By the time of World Health Organization 1986, substantial knowledge had accrued to support recommendations at both the national and community levels. Further development of community-level guidelines is shown by Pearson, et al. 2003, an AHA scientific statement on this topic. Musgrove and Fox-Rushby 2006 provides an introduction to cost-effectiveness studies and their role in policy development and decision making. Applicability of risk prediction models across populations is a question of importance because such models are used to determine at what level of risk intervention is warranted; Brindle, et al. 2006 shows significant under- or overestimation of risk from one population to another when a given model is used, suggesting a need for population-specific validation. The European Society of Cardiology’s ongoing study of cardiology practices in relation to guidelines for CVD prevention and treatment, called Euroaspire, is a tool for monitoring and improving patient care across Europe. Lloyd-Jones, et al. 2010 presents a new kind of strategic goal for the American Heart Association, including a 20 percent improvement in cardiovascular health for all Americans by the year 2020. More than a simple inversion of the conventional goals of reducing risk and event rates, this new goal calls for a different view of cardiovascular health, with innovative policies and intervention approaches. (For more extensive coverage and continuous updates on current recommendations, policies, and guidelines for cardiovascular health promotion and CVD prevention, readers may find many of the journals cited in this article as a whole to be useful sources.)

                                                                                                                                                                                                              • Brindle, P., A. Beswick, T. Fahey, and S. Ebrahim. 2006. Accuracy and impact of risk assessment in the primary prevention of cardiovascular disease: A systematic review. Heart 92.12: 1752–1759.

                                                                                                                                                                                                                DOI: 10.1136/hrt.2006.087932Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                This analysis addresses the impact on prediction of CVD risk when a prediction model is applied to various populations. Recent Framingham risk models, for CHD or CVD as the outcome, were applied to twenty-seven study populations. Events were overpredicted in low-risk populations, and, conversely, with important implications for treatment policies.

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                                                                                                                                                                                                                • Euroaspire III Survey: EHS on Secondary and Primary Prevention of Coronary Heart Disease.

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                                                                                                                                                                                                                  The question of whether clinical guidelines are implemented in practice is addressed in an ongoing program, Euroaspire, described in this and previous reports. The focus is on cardiology practices and recorded evidence of intervention on lifestyle factors and with recommended treatments. Changes in patient characteristics and physician practices are being monitored.

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                                                                                                                                                                                                                  • Lloyd-Jones, D. M., Y. Hong, D. Labarthe, et al. 2010. Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association’s strategic impact goal through 2020 and beyond. Circulation. 121:586–613.

                                                                                                                                                                                                                    DOI: 10.1161/CIRCULATIONAHA.109.192703Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                    Building on evidence that low cardiovascular risk at middle age predicts a longer, healthier life and lower health care costs than occur with even one major risk factor, AHA adopted the 2020 goal of improving cardiovascular health. This calls for new definitions, targets, strategies, and metrics, addressed in this report.

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                                                                                                                                                                                                                    • Musgrove, P., and J. Fox-Rushby. 2006. Cost-effectiveness analysis for priority setting. In Disease Control Priorities in Developing Countries. 2d ed. Edited by D. T. Jamison, J. G. Breman, A. R. Measham, et al., 271–285. Washington, DC: World Bank.

                                                                                                                                                                                                                      DOI: 10.1596/978-0-8213-6179-5/Chpt-15Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                      Cost-effectiveness assessment is a tool in policy decision making with which many in the field of CVD prevention are unfamiliar. Especially in low-resource settings with intensely competing demands, this aspect of policy evaluation is critical. This chapter serves as a valuable primer. Copublished with Oxford University Press.

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                                                                                                                                                                                                                      • Pearson, T. A., T. L. Bazzarre, S. R. Daniels, et al. 2003. American Heart Association guide for improving cardiovascular health and the community level: A statement for public health practitioners, healthcare providers, and health policy makers from the American Heart Association Expert Panel on Population and Prevention Science. Circulation 107:645–651.

                                                                                                                                                                                                                        DOI: 10.1161/01.CIR.0000054482.38437.13Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                        While recommendations and guidelines for clinical intervention in CVD are abundant, corresponding resources for public health interventions in communities have been scarce and were largely absent from the AHA portfolio of policy statements until the publication of this report. A wide range of recommendations and their rationale are presented here.

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                                                                                                                                                                                                                        • World Health Organization. 1957. Study Group on Atherosclerosis and Ischaemic Heart Disease: Report. WHO Technical Report 117. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                                                                          This report recognizes that a number of approaches to CVD prevention had been suggested by the mid-1950s, but that evidence was insufficient to support any of them as a matter of prevention policy. Research was called for throughout the world to fill this significant gap.

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                                                                                                                                                                                                                          • World Health Organization. 1986. Community prevention and control of cardiovascular diseases. WHO Technical Report 732. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                                                                            This report embraces the recommendations of a comprehensive WHO Expert Committee report of 1982 and presents methods for community-level implementation of its recommendations and a model regional plan for CVD prevention.

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                                                                                                                                                                                                                            Making the Case for Prevention

                                                                                                                                                                                                                            The case for prevention is supported from several perspectives, although countervailing views are encountered. Labarthe 2011 summarizes the prevailing views and notes, as well as the principal lines of counterargument. Among a great many studies supporting the case for CVD prevention, one is the example of success in Finland addressed in Vartiainen, et al. 1994. This report shows the intermediary role of risk factor reductions in explaining the decrease in ischemic heart disease mortality since 1972, when intervention began, in one region. Farquhar and Fortmann 2005 summarizes a broad experience with community-level education programs to bring about health behavior change. World Bank 2005 documents the devastating impact of CVD and other noncommunicable diseases in the Russian Federation, calling for urgent and substantial interventions to reverse the course. Lloyd-Jones, et al. 2006 shows the lifelong impact of a favorable risk profile at age fifty, demonstrating newer methods of analysis to understand risk factors from a life-course perspective. International Heart Health Society 2005 presents a platform for effective strategies of cardiovascular health promotion throughout the world, bringing together recommendations from the society’s four previous conference reports. Bloom, et al. 2011 considers the full economic impact of the global burden of noncommunicable diseases in an extensive report on the macroeconomic impacts of these conditions, including mental illness. In the United States as well, as presented in Heidenreich, et al. 2011, the forecast of the economic burden of CVD presents a dire picture of the future, but with the sense that effective interventions have the potential to turn the picture around.

                                                                                                                                                                                                                            • Bloom, D. E., E. T. Cafiero, E. Jané-Llopis, et al. 2011. The global economic burden of non-communicable diseases. Geneva, Switzerland: World Economic Forum.

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                                                                                                                                                                                                                              The major messages are: a forecast of “staggering” economic burden over the next two decades; middle-income countries’ share of the burden increasing soon; cardiovascular disease and mental health conditions predominating in the burden; mounting concern by business leaders about noncommunicable disease; and an inventory of “best buys” for cost-effective interventions. Copublished with the Harvard School of Public Health.

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                                                                                                                                                                                                                              • Farquhar, J. W., and S. P. Fortmann. 2005. Community-based health promotion. In Handbook of Epidemiology. Edited by W. Ahrens and I. Pigeot, 1306–1321. Berlin: Springer.

                                                                                                                                                                                                                                DOI: 10.1007/978-3-540-26577-1Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                This review of experience with community-level CVD prevention programs concludes that three decades of health promotion in whole communities, in the developed world, has shown an impact on health behaviors through transfer of public education technologies to the community infrastructure. Education leads to community-level self-efficacy and favorable change.

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                                                                                                                                                                                                                                • Heidenreich, P. A., J. G. Trogdon, O. A. Khavjou, et al. 2011. Forecasting the future of cardiovascular disease in the United States: A policy statement from the American Heart Association. Circulation 123:933–944.

                                                                                                                                                                                                                                  DOI: 10.1161/CIR.0b013e31820a55f5Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                  Within the United States alone, total economic costs attributable to CVD are projected to increase to more than $1 trillion by 2030, unless effective measures are taken to reverse this trajectory. The economic argument for prevention gains strength as such analyses are conducted country by country and globally.

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                                                                                                                                                                                                                                  • International Heart Health Society. 2005. International action on cardiovascular disease: A platform for success based on international cardiovascular disease (CVD) declarations. Vancouver, Canada: International Heart Health Society.

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                                                                                                                                                                                                                                    Policy declarations issued at each of five International Heart Health Conferences, from 1992–2001, are synthesized into this document, presenting a broad policy framework for CVD prevention and cardiovascular health promotion globally.

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                                                                                                                                                                                                                                    • Labarthe, D. R. 2011. The case for prevention. In Epidemiology and prevention of cardiovascular diseases: A global challenge. 2d ed. By D. R. Labarthe, 619–656. Sudbury, MA: Jones and Bartlett.

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                                                                                                                                                                                                                                      Three lines of argument are most often encountered in opposition to strategies for CVD prevention: knowledge of causation is insufficient; means of prevention are inadequate or too costly; and only with further research could interventions become supportable as public health investments. Several citations link the reader with this literature.

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                                                                                                                                                                                                                                      • Lloyd-Jones, D. M., E. P. Leip, M. G. Larson, et al. 2006. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 113:791–798.

                                                                                                                                                                                                                                        DOI: 10.1161/CIRCULATIONAHA.105.548206Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                        Follow-up from ages fifty to ninety-five in the Framingham Heart Study shows that lifetime risk of CVD is least among those with zero risk factors, and increases incrementally with each additional risk factor, as determined at age fifty. These are powerful predictors throughout the adult years.

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                                                                                                                                                                                                                                        • Vartiainen, E., P. Puska, J. Pekkanen, J. Tuomilehto, and P. Jousilahti. 1994. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. BMJ 309.6946: 23–27.

                                                                                                                                                                                                                                          DOI: 10.1136/bmj.309.6946.23Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                          Among successes of CVD prevention policy, Finland offers the preeminent example. A commonly posed question is whether the policies first evaluated in the area of North Karelia account for the marked decline in IHD mortality. This report addresses that question, finding risk factor reductions closely parallel with reduced mortality.

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                                                                                                                                                                                                                                          • World Bank. 2005. Dying too young: Addressing premature mortality and ill health due to non-communicable diseases and injuries in the Russian Federation. Washington, DC: World Bank.

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                                                                                                                                                                                                                                            The World Bank demonstrates the devastating impact of epidemic cardiovascular disease and noncommunicable diseases, with documentation of their burden in the Russian Federation. Life expectancy has decreased significantly with population shrinkage and losses from the workforce. The economic impact makes investment in reversal of this circumstance, if successful, hugely beneficial.

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                                                                                                                                                                                                                                            Action Plans

                                                                                                                                                                                                                                            Action plans based on policy priorities translate these into concrete tasks, as in Centers for Disease Control and Prevention 2003. Such plans provide action agendas designed to achieve the goals of policy. The National Action Plan for Pakistan (Pakistan Ministry of Health, et al. 2004) shares these features but is specific to the needs and priorities of that country and combines cardiovascular diseases with other noncommunicable diseases for coordination of interventions. World Health Organization 2005 further demonstrates that policies alone, such as the product of the 2000 World Health Assembly, require the further elaboration of action steps to have a concrete effect. Ministers of Health of the Americas 2007 charts a course for the years 2008–2017 for the region, delineating action areas to be pursued by every country. Such regional plans, intermediate between global strategies such as those of the WHO and national plans, are necessarily less specific, but they offer guidance reflecting regional concerns and priorities. World Health Organization 2008 outlines broad lines of supporting action, in a follow-up to adoption of the Global Strategy (see World Health Organization 2004, cited under Dietary Imbalance). In Canada, the need for a national plan led to a process not unlike that of developing the US Action Plan (Centers for Disease Control and Prevention 2003); it was anticipated that government would respond to the plan by supporting its implementation—which, however, is unavoidably affected by changing political priorities (Canadian Heart Health Strategy and Action Plan). The Million Hearts Initiative, launched in the United States in September 2011, illustrates a federal government action with multiple parts, all depending on activating provisions of the recent health reform legislation, with the goal to prevent one million heart attacks and stroke over the five years from beginning implementation (see Frieden and Berwick 2011).

                                                                                                                                                                                                                                            Research Directions

                                                                                                                                                                                                                                            Research in cardiovascular disease (CVD) epidemiology and prevention begins with the public health function of surveillance, addressed by Thacker 2000, a comprehensive text on this topic. Bonita, et al. 2001 describes one approach to noncommunicable disease surveillance, the World Health Organization’s STEPWise approach, with incremental addition of components as circumstances in a particular country or locality permit. As an example of the continuing importance of population-based cohort studies, National Heart, Lung, and Blood Institute 2006 presents data and cites published reports on the design and methods of the Atherosclerosis Risk in Communities (ARIC) Cohort Study, Cardiovascular Health Study (CHS), Coronary Artery Risk Development in Young Adults (CARDIA), Framingham Heart Study (FHS), Multi-Ethnic Study of Atherosclerosis (MESA), and Strong Heart Study (SHS), as well as ARIC Surveillance. Goff, et al. 2007 addresses current CVD surveillance in the United States and means of strengthening it at national, state, and local levels. Aboderin, et al. 2001 calls for research that addresses a life course approach, taking into account the developmental processes through which risk and disease arise and progress over time in individuals. Maden, et al. 2007 points to implementation science as a newly conceived approach to the study of health systems, especially in developing countries. A chapter in Labarthe 2011 reviews research agendas in CVD epidemiology and prevention and suggests that the scale of this research has grown; Labarthe calls for an innovative concept of research for population health, “populomics.” Homer, et al. 2010 illustrates the application of system dynamics research methods (akin to syndemics research) to the evaluation of policy alternatives in CVD prevention. (For more extensive coverage and continuous updates on research in public health aspects of cardiovascular health and disease, readers may find many of the journals cited in this article as a whole to be useful sources.).

                                                                                                                                                                                                                                            • Aboderin, I., A. Kalache, Y. Ben-Shlomo, et al. 2001. Life course perspectives on coronary heart disease, stroke and diabetes: Key issues and implications for policy and research. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                                                                                              The “life course concept” recognizes the development of patterns of behavior, environmental exposures, risks, and disease and disability throughout life. Research questions derived from this concept in relation to CVD could address individual and population differences in the time course of disease development, optimum points for intervention, and others.

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                                                                                                                                                                                                                                              • Bonita, R., M. de Courten, T. Dwyer, K. Jamrozik, and R. Winkelmann. 2001. Surveillance of risk factors for noncommunicable diseases: The WHO STEPwise approach–Summary. Geneva, Switzerland: World Health Organization.

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                                                                                                                                                                                                                                                WHO developed, and has implemented in many countries, its STEPWise approach to NCD surveillance, in which Step 1 uses questionnaire methods, Step 2 adds physical examination, and Step 3 further adds biochemical evaluations. At each step, core and supplemental components are available for use in keeping with interests and resources.

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                                                                                                                                                                                                                                                • Goff, D. C., Jr., L. Brass, L. T. Braun, et al. 2007. Essential features of a surveillance system to support the prevention and management of heart disease and stroke: A scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Stroke, and Cardiovascular Nursing and the Interdisciplinary Working Groups on Quality of Care and Outcomes Research and Atherosclerotic Peripheral Vascular Disease. Circulation 115:127–155.

                                                                                                                                                                                                                                                  DOI: 10.1161/CIRCULATIONAHA.106.179904Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                  Key measures of CVD for policy development and program design and evaluation include incidence, case fatality, and recurrence rates, among others. This report reviews strengths and limitations of CVD surveillance in the United States at the national, state, and local levels, and recommends improvements to provide more effectively the data needed for planning.

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                                                                                                                                                                                                                                                  • Homer, J., B. Milstein, K. Wile, J. Trogdon, P. Huang, D. Labarthe, et al. 2010. Simulating and evaluating local interventions to improve cardiovascular health. Preventing Chronic Disease 7.1.

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                                                                                                                                                                                                                                                    System dynamics research addresses here the complex relations among influences on CVD occurrence and their potential responsiveness to interventions. Alternative strategies and combinations of specific interventions are evaluated for their differential impacts on rates of first CVD events, from 1990 to 2040.

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                                                                                                                                                                                                                                                    • Labarthe, D. R. 2011. Epidemiology and a CVD research agenda. In Epidemiology and prevention of cardiovascular diseases: A global challenge. 2d ed. By D. R. Labarthe, 679–696. Sudbury, MA: Jones and Bartlett.

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                                                                                                                                                                                                                                                      Research agendas proposed by various authoritative bodies in the arena of CVD prevention and control are reviewed. Dimensions of epidemiologic research have expanded greatly in time, place, and person, calling for greater connectivity across disciplines and subjects relevant to population health. “Populomics” is a term that captures this concept.

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                                                                                                                                                                                                                                                      • Maden, T., K. J. Hofman, L. Kupfer, and R. I. Glass. 2007. Implementation science. Science 318: 1728–1729.

                                                                                                                                                                                                                                                        DOI: 10.1126/science.1150009Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                        “Implementation research” or “implementation science” is proposed here by the US Fogarty International Center to strengthen health care, especially in developing countries. A series of questions constitute a research agenda for health system scale-up that is contemplated in improved long-term management of noncommunicable diseases, as well as addressing other conditions.

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                                                                                                                                                                                                                                                        • National Heart, Lung, and Blood Institute. 2006. Incidence and prevalence: 2006 chart book on cardiovascular and lung diseases. Bethesda, MD: National Heart, Lung, and Blood Institute.

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                                                                                                                                                                                                                                                          This aggregation of data from multiple population-based cohort studies of CVD in the United States illustrates the contribution of such studies in ongoing epidemiologic research. Each focuses on a specific age level at entry or one or more population groups defined by race/ethnicity. Especially relevant to surveillance is the ARIC study.

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                                                                                                                                                                                                                                                          • Thacker, S. B. 2000. Historical development. In Principles and practice of public health surveillance. 2d ed. Edited by S. M. Teutsch and R. E. Churchill, 1–16. Oxford: Oxford Univ. Press.

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                                                                                                                                                                                                                                                            A core function of public health is to assess the health of the population, and the primary approach to this function is surveillance. This text reviews the origins, methods, and operational aspects, after an introduction to the topic in this lead chapter.

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