Policy as intervention: environmental and policy approaches to the prevention of cardiovascular disease.

This paper describes the evolution of efforts to prevent cardiovascular disease, from individual health education approaches to broader community education efforts and, finally, to comprehensive and integrated programs addressing environmental, policy, and individual behavior change. Policies are divided into two areas: legislation/regulation and organizational policy. Environmental strategies are measures that alter or control the physical or social environment. Dimensions along which these strategies might be implemented are provided. Policy and environmental approaches can be justified on economic, strategic, and theoretical grounds. Experiences from other fields and other countries provide a framework for conceptualizing cardiovascular disease prevention approaches.     

New York inmates' HIV risk behaviors: the implications for prevention policy and programs.

OBJECTIVES: The median incidence rate of acquired immunodeficiency syndrome (AIDS) among prisoners is 7 times higher than for the general population. Yet high-risk sexual activity and drug use in US correctional facilities remain unexamined. This study explores inmate perceptions of high-risk behavior in New York state prisons and New York City jails and seeks to generate hypotheses to inform policies and future research. METHODS: Participants were 22 former New York state prisoners and 28 current New York City inmates. Participants attended one of six focus groups and completed an anonymous questionnaire. Audiotapes of the groups were transcribed and evaluated. RESULTS: A range of consensual and nonconsensual sexual activity occurs among inmates and between inmates and staff. Without official access to latex barriers, prisoners use ineffective makeshift devices, like rubber gloves and used plastic wrap, in attempts to practice safer sex. Prisoners also shoot drugs intravenously with used syringes and pieces of pens and light bulbs. CONCLUSIONS: The absence of harm-reduction devices behind bars may create a greater risk of HIV transmission there than in the community. Officials should consider distributing risk-reduction devices to prisoners through anonymous methods.     

Progress in prevention of cardiovascular disease

Remarkable progress has been made in understanding the basic processes involved in cardiovascular diseases, as well as in our ability to detect and treat these diseases. This in turn has led to a striking decrease in mortality from cardiovascular disease. At the same time, it is evident that primary prevention must be our ultimate goal. Given the limitations in resources, this is clearly the most cost-effective approach. Epidemiologists and other researchers have defined a large number of cardiovascular risk factors, of which the major ones are age, male sex, hypertension, cigarette smoking, plasma LDL and HDL cholesterol, and blood glucose. Other risk factors include overweight, sedentary lifestyle, water hardness, family history of heart disease before age 65, personality type and stress. The National Heart, Lung, and Blood Institute has launched a three-pronged attack, aimed ultimately at primary prevention and involving activities throughout the biomedical research continuum. We must: (a) support more varied and creative research into the basic mechanisms in the etiology and pathophysiology of arteriosclerosis and hypertension—two processes whose primary mechanisms are still not fully understood, but whose devastating consequences produce most of the morbidity: (b) support clinical trials and other definitive validation exercises to test the assumption that alteration of risk factors will decrease risk; (c) support joint research between the behavioral and biomedical communities so that they may unite their efforts toward learning how to change lifestyles and helping our citizens help themselves. We must be ready today to expeditiously translate to the public those findings that have already been validated and will lead to a healthier and longer life. Areas of controversy should be publicized so that individuals may make their own choices. Public awareness of and attention to risk factors within the past decade appears to have played a major role in the decline in cardiovascular mortality.     

Israel's prevention programs and screening policies for cardiovascular disease

For all four broad ethnic groups in Israel, mortality rates declined over the last decade for both ischemic heart disease (IHD) and cerebrovascular disease (CVD), the first and third most important causes of death in the country. The four broad ethnic groups consist of persons born in Israel, Asia, North Africa, and Europe. Mortality data also indicate a low male to female ratio in mortality from IHD, a definite female predominance in mortality from CVD, and high mortality rates for IHD and CVD in males and females born in North Africa. Morbidity data, especially incidence, are scarce for CVD in both sexes and IHD in females. The feasibility of preventive intervention needs to be tested under the specific conditions of Israel. Although a multiple risk factor trial in Jerusalem showed that such a program can be conducted in a primary care framework, it clearly still needs to be tested in clinics rather than in a model teaching institution. The best place for intervention would seem to be the primary health care system, which has almost complete access to the country's population. Kupat Holim (the Health Insurance Institute of the General Federation of Labour) is attempting systematically to identify and manage hypertension patients. To date, management of acute coronary disease has been emphasized in Israel. Although additional resources are needed for primary prevention services, other options are suggested for obtaining those services.     

Translating evidence into policy for cardiovascular disease control in India

Cardiovascular diseases (CVD) are leading causes of premature mortality in India. Evidence from developed countries shows that mortality from these can be substantially prevented using population-wide and individual-based strategies. Policy initiatives for control of CVD in India have been suggested but evidence of efficacy has emerged only recently. These initiatives can have immediate impact in reducing morbidity and mortality. Of the prevention strategies, primordial involve improvement in socioeconomic status and literacy, adequate healthcare financing and public health insurance, effective national CVD control programme, smoking control policies, legislative control of saturated fats, trans fats, salt and alcohol, and development of facilities for increasing physical activity through better urban planning and school-based and worksite interventions. Primary prevention entails change in medical educational curriculum and improved healthcare delivery for control of CVD risk factors-smoking, hypertension, dyslipidemia and diabetes. Secondary prevention involves creation of facilities and human resources for optimum acute CVD care and secondary prevention. There is need to integrate various policy makers, develop effective policies and modify healthcare systems for effective delivery of CVD preventive care.     

Occupational and environmental medicine in New York State

New York State (NYS) is home to 7.2% of the population and producer of 8.4% of the gross domestic product of the United States. The history and the current status of occupational and environmental medicine (OEM) research, educational resources, clinical practice patterns, and regulatory framework in NYS are reviewed. Changes anticipated or already taking place in health care financing, clinical practice patterns, occupational safety and health regulations and enforcement, and funding for research and medical education at the national level, are already having an impact in OEM activities in NYS. Received: 11 December 1996 / Accepted: 20 December 1996     

Nutrition protocols for the prevention of cardiovascular disease

Cardiovascular disease is the number one cause of death in the United States, and prevention of cardiovascular disease is at the top of the public health agenda. Evidence shows that reducing the incidence of coronary heart disease with diet is possible. More than a half century of evidence from epidemiologic, experimental, and clinical trials pinpoints a positive correlation between lifestyle and dietary factors as they relate to blood lipids, blood pressure, and coronary heart disease risk, and a number of evidence-based nutrition guidelines have emerged. The National Cholesterol Education Program's Therapeutic Lifestyle Changes diet includes unsaturated fats, fiber, and plant sterols/stanols. The whole foods approach incorporates increased consumption of fruits, vegetables, whole grains, and fish; and the American Heart Association guidelines emphasize functional foods like soy protein, nuts, and alcohol. These guidelines display the rationale for nutrition intervention as a primary prevention for cardiovascular disease. In addition, body weight, body mass index, waist circumference, and waist-to-hip ratio are examined as risk factors for cardiovascular disease. This article highlights key nutrients and lifestyle factors in preventing cardiovascular disease and identifies practical applications for clinicians.     

The evidence for dietary prevention and treatment of cardiovascular disease

During the past few decades numerous studies have reported the atherogenic potential of saturated fatty acids, trans-fatty acids, and cholesterol, and beneficial effects of fiber, phytostanols/phytosterols, n-3 fatty acids, a Mediterranean diet, and other plant-based approaches. The purpose of this article is to provide a comprehensive and systematic review of the evidence associated with key dietary factors and risk of cardiovascular disease-an umbrella term encompassing diseases that affect the heart and blood vessels, including coronary heart disease, coronary artery disease, dyslipidemia, and hypertension-in conjunction with the work of the American Dietetic Association Evidence Analysis Library review on diet and lipids, updated with new evidence from the past 2 years. The criteria used and results cited provide scientific rationale for food and nutrition professionals and other health professionals for counseling patients. Details of these searches are available within the American Dietetic Association Evidence Analysis Library online (http://adaevidencelibrary.com). Potential mechanisms and needs for future research are summarized for each relevant nutrient, food, or food component.     

The ATS-Sardegna Campaign for cardiovascular disease prevention and health promotion

The ATS-Sardegna Campaign is a community-oriented initiative for cardiovascular disease prevention and health promotion, spreading throughout the whole island of Sardinia. The campaign was planned and is being carried out by the Centre of Cagliari, which pertains to the Italian Group for the Study of Metabolic Diseases and Atherosclerosis. The campaign is financed by the Sardinian Department of Public Health. The programme adopted both a population strategy and an individual (high-risk) strategy, and takes advantage of the experience gained by the Cagliari Centre as an Operative Unit of the Italian National Research Council. The population strategy is based on repeated educational messages in local daily newspapers and on TV networks, and through the distribution, free of charge, to all Sardinian households of an illustrated booklet that is written in a similar fashion as a car maintenance hand-book. The individual strategy relies upon general practitioners with full collaboration from the Sardinian Medical Associations, in order to involve the doctors in the promotion of preventive medicine. The ATS-Sardegna Campaign is designed in such a way as to ensure the transferability of its protocol to other Italian regions, and so to act as the first stage of a national programme.

     

Dietary change for cardiovascular disease prevention among Black-American families

A center-based cardiovascular disease prevention program wasconducted as a feasibility study to lower sodium and saturatedfat in the diets of Black-American families with fifth throughseventh grade children in one southwest city. Ninety-six familieswere actively recruited and randomly assigned to experimentalor control groups. The experimental group was encouraged toattend 14 consecutive weeks of education sessions at a centralfacility.Social learning, social support and adult educationtheories guided the design of sessions which emphasized active,participatory learning. A 2-week food frequency questionnaireand 24-h dietary recall were measures of the dependent variables.Behavioral capability and self-efficacy for dietary change werealso assessed. A post-program, formative evaluation interviewwas conducted with one adult per family in the experimentalgroup. Program participants reported less frequent consumptionof high sodium foods (especially for boys). Low rates of attendancewere recorded after the fourth week of the program. Participantsreported that attendance was impeded by conflicts with workand school and a dislike for completing dietary self-monitoringforms. Future efforts to reach healthy Black-American adultsshould integrate such a program into other on-going communityactivities and avoid intensive diet self-monitoring procedures.     

Advances in the prevention and treatment of cardiovascular disease

Over the past thirty-five years, U.S. age-adjusted mortality from cardiovascular disease declined 50 percent. This marked reduction reflects advances in the prevention, diagnosis, and treatment of common cardiovascular conditions. Pharmaceutical agents play a major role in prevention of atherosclerosis and its consequences: heart attack, stroke, and heart failure. Additionally, novel device-based therapies contribute to the decline in cardiac morbidity and mortality. Whereas innovative strategies based on accurate imaging of the heart and blood vessels are implemented widely now, hope exists that lifestyle changes, early risk-factor screening, and more efficacious drugs will strikingly reduce cardiovascular disease in the future.