New Concepts and Strategies for Prevention of Cardiovascular Disease Nathan D. Wong, PhD, FACC, FAHA...

New Concepts and Strategies for Prevention of Cardiovascular Disease

Nathan D. Wong, PhD, FACC, FAHAProfessor and Director, Heart Disease Prevention ProgramDivision of Cardiology, University of California, IrvineImmediate Past President, American Society for Preventive Cardiology

Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease. 2010 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2010

CVD and other major causes of death for all males and females (United States: 2007).

CVD disease mortality trends for males and females (United States: 1979-2006). Source: NCHS and NHLBI.

Chart1

496.676466.361

506.154487.194

487.453495.286

444.763475.482

452.452503.139

440.175505.661

398.563432.709

Males

Females

Years

Deaths in Thousands

Sheet1

CVDCVDCardiovascular Disease Mortality Trends for Males and FemalesCVD *CVD*CVDCVD

MalesFemalesUnited States: 1979-2006MalesFemalesMalesFemales

795004697949746679497466

805104908050648780506487

8150048449748185487495

8249548449248190445475

8349849449549195452503

8449149348749100440506

854914988548749506399433

86481498478495

87475499472496

88476504473501

89456486453483

9044847890445475

91447479444477

92444479441477

93457500454498

94452498449496

9545550595452503

96453506451504

97450503448501

98446504Actual MortalityAdjusted Mortality*443502

99446513adjusted by 9-10 comparability ratio. (0.9981)445.024511.929446513

00440506440.175505.661439.339504.70000440506

01432499432.245498.863431.424497.915432499

Source: Final mortality data, NCHS.433.827493.69002433.003492.752434494

Numbers are in thousands.427.891483.37203427.078482.454428483

CVD including congenital CV disease.410.365461.15204409.585460.276411459

05410455

* - Since comparability ratio is so close to 1.00

it is not necessary to adjust. As per TT 9/26/06.

Sheet1

Males

Females

Years

Deaths in Thousands

Percentage breakdown of deaths from cardiovascular diseases (United States:2004) Source: NCHS and NHLBI.

Chart1

52

17

7

6

4

14

PieCVD

2003CVD total mortality2004 CVD total mortality final2004 CVD total mortality final

910,614PreliminaryPercentage Breakdown of Deaths From Cardiovascular DiseasesPercentage Breakdown of Deaths From Cardiovascular Diseases

479,304CHD52.6Coronary Heart Disease52451,32652United States:2004Coronary Heart Disease52451,32652United States:2004

157,803Stroke17.3Stroke17150,07417Stroke17150,07417

57,218HF6.3HF757,1207HF757,1207

52,604Hyp.5.8High Blood Pressure654,7076High Blood Pressure654,7076

37,647Dis. of Arteries4.1Diseases of the Arteries435,5544Diseases of the Arteries435,5544

4,178Cong.HD0.5Congenital Cardiovascular Defects0.43,8610.4Other14120,94314

3,554RF/RHD0.4Rheumatic Fever/Rheumatic Heart Disease0.43,2540.4869724100.0

118,306Other13.0Other13113,82813

910614100.0869724100.0

Note - CHD is 52 not 53.

Note: Try to arrange in descending order.

959,368Percentage Breakdown of Deaths From Cardiovascular Diseases

529659CHD55.2Coronary Heart Disease54502,18954United States:1980

167,366Stroke17.4Stroke18163,53818

54,920CHF38.9Congestive Heart Failure652,8286

42,997Hyp.4.5High Blood Pressure546,7655

14,979Dis. of Arteries1.6Diseases of the Arteries439,4044

3,676RF/RHD0.4Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4

4657Cong.HD0.5Congenital Cardiovascular Defects0.44,1090.4

141114Other15.5Other13118,78613

959368134.0100.8931,108100.0

1990 CVD total mortality1990CVD total mortality

959,368Percentage Breakdown of Deaths From Cardiovascular Diseases

529659CHD55.2Coronary Heart Disease54502,18954United States:1990

167,366Stroke17.4Stroke18163,53818

54,920CHF38.9Congestive Heart Failure652,8286

42,997Hyp.4.5High Blood Pressure546,7655

14,979Dis. of Arteries1.6Diseases of the Arteries439,4044

3,676RF/RHD0.4Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4

4657Cong.HD0.5Congenital Cardiovascular Defects0.44,1090.4

141114Other15.5Other13118,78613

959368134.0100.8931,108100.0

&A

Page &P

PieCVD

53%

LCDAIAF

LCDWHITEMF

LCDMF

LCDBLKMF

LCD AM. INDIAN M/F, 2003

Diseases of the Heart and Stroke and other Major Causes of Death for American Indian/Alaska Native Males and Femlaes

MALESFEMALESUnited States: 2003

Diseases of the Heart, and StrokeA24.9Diseases of the Heart, and StrokeA24.7

CancerB15.4CancerB17.6

AccidentsC14.7AccidentsC8.8

Diabetes MellitusD5.2DiabetesD6.9

Chronic Liver Disease and CirrhosisE4.5Chronic Liver Disease and CirrhosisE4.2


United States: 2003

Females

Males

MALES

Diseases of the Heart, and Stroke24.9FEMALES

Cancer15.4Diseases of the Heart, and Stroke24.7

Accidents14.7Cancer17.6

Diabetes Mellitus5.2Accidents8.8

Chronic Liver Disease and Cirrhosis4.5Diabetes Mellitus6.9

Chronic Liver Disease and Cirrhosis4.2

Diseases of the Heart and Stroke and other Major Causes of Death for American Indian/Alaska Native Males and FemlaesDiseases of the Heart and Stroke and other Major Causes of Death for American Indian/Alaska Native Males and Femlaes

United States: 2003United States: 2003

LCD AM. INDIAN M/F, 2004

MALESFEMALES

Diseases of the Heart, and StrokeA23.6Diseases of the Heart, and StrokeA25.0



Diabetes MellitusD5.1DiabetesD6.4

Chronic Liver Disease and CirrhosisE4.5Chronic Liver Disease and CirrhosisE4.2

ABCDEABCDE

Males23.617.414.25.14.5

Females25.019.28.56.44.2


United States: 2004

&A

Page &P

LCDBLKMF

0

0

0

0

0

MALES

Percent of Total Deaths

LCDAPI

0

0

0

0

0

`

FEMALES


lcdkids

0

0

0

0

0


LCD3stacked

0

0

0

0

0


LCDHISPMF

00

00

00

00

00

00

00

00

00

00

Males

Females


CVD and Other Major Causes of Death for White Females

LCD WHITE M/F, 2004United States: 2004

10251961077393

MALESFEMALES

CVD+cong.A34.9CVD+cong.A37.7


AccidentsC5.9Chronic LRDD5.7

Chronic LRDD5.4Alzheimer'sF4.1

DiabetesE2.8AccidentsC3.2

CVD and Other Major Causes of Death for White Males

United States:2004

Females

Males

MALES

Total CVD34.9FEMALES

Cancer24.5Total CVD37.7

Accidents5.9Cancer21.8

Chronic Lower Respiratory Disease5.4Chronic Lower Respiratory Disease5.7

Diabetes Mellitus2.8Alzheimer's Disease4.1

CVD and Other Major Causes of Death for White MalesAccidents3.2

United States: 2004

CVD and Other Major Causes of Death for White Females

United States: 2004

Males

Females

LCD WHITE M/F, 2004

10251961077393

MALESFEMALES



AccidentsC5.9Chronic LRDD5.7

Chronic LRDD5.4Alzheimer'sF4.1


ABCDEABDFC

Males34.924.55.95.42.8

Females37.721.85.74.13.2

CVD and Other Major Causes of Death for White Males and Females

United States:2004

&A

Page &P

0

0

0

0

0

MALES


0

0

0

0

0

FEMALES


0

0

0

0

0

FEMALES


0

0

0

0

0

Percent ofTotal Deaths

00

00

00

00

00

00

00

00

00

00

Males

Females


LCD MALES AND FEMALES, 2004CVD and Other Major Causes of Death for All Males and Females

United States: 2004

MALESFEMALES

CVD+cong.A410,365CVD+cong.A461,152

CancerB285,258CancerB265,013

AccidentsC69,791Chronic LRDD64,409

Chronic LRDD59,476Alzheimer'sF46,954

DiabetesE35,043DiabetesE37,771

CVD and Other Major Causes of Death for All Males and Females

United States: 2004

Females

Males

LCD, 2002

Total CVD433,825

Cancer288,768

Accidents69,257

Chronic Lower Respiratory Disease60,713

Diabetes Mellitus34,301

Leading Causes of Death

United States: 2002

LCD MALES AND FEMALES, 2004

MALESFEMALES

CVD+cong.A410,628CVD+cong.A459,096

CancerB286,830CancerB267,058

AccidentsC72,050Chronic LRDD63,341

Chronic LRDD58,646Alzheimer'sF46,991

DiabetesE35,267AccidentsC39,962

ABCDEABDFC

Males410,628286,83072,05058,64635,267

Females459,096267,05863,34146,99139,962

CVD and Other Major Causes of Death for All Males and Females

United States: 2004

&A

Page &P

0

0

0

0

0

MALES

Deaths in Thousands

0

0

0

0

0

FEMALES

Deaths in Thousands

0

0

0

0

0

Deaths in Thousands

Males

Females

Deaths in Thousands

LCD BLACK M/F, 2004LCD BLACK M/F, 2004

CVD and Other Major Causes of Death for Black Males and Females

MALESFEMALESUnited States: 2004MALESFEMALES

CVD+cong.A32.7CVD+cong.A40.0CVD+cong.A32.7CVD+cong.A40.0

CancerB22.4CancerB21.2CancerB22.4CancerB21.2

AccidentsC5.7DiabetesE5.1AccidentsC5.7DiabetesE5.1

Assault(Homicide)D4.6Nephritis, etc.F3.1Assault(Homicide)D4.6Nephritis, etc.F3.1

DiabetesE3.8AccidentsC2.8DiabetesE3.8AccidentsC2.8

CVD and Other Major Causes of Death for Black Males and FemalesMalesFemales

United States: 2004A32.740.0

B22.421.2

C5.72.8

D4.60.0

E3.85.1

F0.03.1

Top 5


Females

Males

Charts for "Fact Sheets"

MALESFEMALES

Total CVD32.7Total CVD40.0`

Cancer22.4Cancer21.2

Accidents5.7Diabetes Mellitus5.1

Assault(Homicide)4.6Nephritis, Nephrotic Syndrome and Nephrosis3.1

Diabetes Mellitus3.8Accidents2.8

CVD and Other Major Causes of Death for Black Males and FemalesCVD and Other Major Causes of Death for Black Males and Females


CVD - Cardiovascular diseases including congenital cardiovascular defects. Preliminary data.CVD - Cardiovascular diseases including congenital cardiovascular defects. Preliminary data.

MalesFemales

LCD BLACK M/F, 2004

MALESFEMALES



AccidentsC5.7DiabetesE5.1

Assault(Homicide)D4.6Nephritis, etc.F3.1


ABCDEABEFC

Males32.722.45.74.63.8

Females40.021.25.13.12.8


United States: 2004

&A

Page &P

0

0

0

0

0

MALES


0

0

0

0

0

FEMALES


0

0

0

0

0


0

0

0

0

0


00

00

00

00

00

00

Males

Females


00

00

00

00

00

00

00

00

00

00

Males

Females


MalesFemales

Diseases of Heart and StrokeA34.0Diseases of Heart and StrokeA34.7



Chronic Lower Respiratory DiseaseD3.8Diabetes MellitusE3.9

DiabetesE3.3Influenza and PneumoniaF3.0

Diseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and FemalesDiseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and Females


MalesFemales

Diseases of Heart and Stroke34.7

Diseases of Heart and Stroke34.0Cancer27.1

Cancer25.5Accidents4.1

Accidents5.6Diabetes Mellitus3.9

Chronic Lower Respiratory Disease3.8Influenza and Pneumonia3.0

Diabetes Mellitus3.3

Diseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and Females

Diseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and FemalesUnited States: 2003

United States: 2003

MalesFemales

MalesFemales

Diseases of Heart and StrokeA32.9Diseases of Heart and StrokeA33.5


AccidentsC5.5Diabetes MellitusE4.0

Chronic Lower Respiratory DiseaseD3.5AccidentsC4.0

DiabetesE3.3Influenza and PneumoniaF3.4

ABCDEABECF

Males32.926.75.53.53.3

Females33.526.94.04.03.4

Diseases of the Heart and Stroke and Other Major Causes of Death for Asian/Pacific Islander Males and Females

United States: 2004

0

0

0

0

0

Females


0

0

0

0

0

Males


0

0

0

0

0


0

0

0

0

0


00

00

00

00

00

00

00

00

00

00

Males

Females


LCD MALE AND FEMALE Children Age

Women and Heart Disease1 in 3 women die of heart disease, but only 4% fear of dying from heart disease1 in 27 women die of breast cancer, but 40% fear of dying of breast cancerOnly 38% of women reported that their doctors had ever discussed heart disease with them.

www.goredforwomen.org/

Development of Atherosclerotic PlaquesNormalFatty streakFoam cellsLipid-rich plaqueLipid coreFibrous capThrombusRoss R. Nature. 1993;362:801-809.

PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early AtherosclerosisPDAY= Pathobiological Determinants of Atherosclerosis in Youth.Strong JP, et al. JAMA. 1999;281:727-735. Fatty streaksRaised lesionsWhite15-1920-2425-2930-340102030Women010203015-1920-2425-2930-34BlackAge (y)0102030White15-1920-2425-2930-34MenBlackIntimal surface (%)

Coronary Calcium Screening: Early Detection of Heart Disease

CT Angiographic Image of the Heart and Coronary Arteries

ACSLADPositive remodeling (+), Soft plaque (+), Fibrous plaque (+), Calcification (-)Motoyama et al. JACC 2007;50:319-26

Prevalence of Multi-Site Atherosclerosis by Gender and Age: MESA Study (CAC, AAC, ABI, and/or CIMT)

Wong ND et al. Atherosclerosis 2011Men Women

Major Risk FactorsAge (men 45 years; women 55 years)Cigarette smoking (and passive smoking)Elevated total or LDL-cholesterolHypertension (BP 140/90 mmHg or on antihypertensive medication)Low HDL cholesterol (

Other Recognized Risk FactorsObesity: Body Mass Index (BMI)Weight (kg)/height (m2)Weight (lb)/height (in2) x 703 Obesity BMI >30 kg/m2 with overweight defined as 25-40 in. in men, >35 in. in womenPhysical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/weekPsychosocial factors: depression, hostility, social isolation, job strain

Six of the top 10 causes of death are lifestyle-related risk factors for cardiovascular disease!

Obesity Trends* Among U.S. Adults: BRFSS - 1985JAMA 1999;282:16, JAMA 2001;286:10.

JAMA 1999;282:16, JAMA 2001;286:10. Obesity Trends* Among U.S. Adults: BRFSS - 1991

By 2020, close to 40% of the US adult population is expected to be obese!Obesity Trends* Among U.S. Adults: BRFSS - 2008

Trends in prevalence of overweight among U.S. children and adolescents by age and survey (NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, unpublished data. NCHS.

Chart4

4.36.611.618.7

3.66.41116.3

1971-74

1976-80

1988-94

2001-2004

Percent of Population

Sheet1

HF PREVALENCECHD MortalityCVD MortalityTotal Mortality

MenWomenNo MetS or DM2.65.314.4

20-390.30.2MetS w/o DM4.37.817.1

40-592.01.5MetS w/DM4.88.621.1

60-797.25.2DM only6.311.526.1

80+11.612.4Prior CVD10.916.730.0

Prior CVD and DM17.028.144.1

Chart 7A: Prevalence of heart failure by sex and ageChart 10A: Total mortality rates in U.S. adults, ages 3075, with metabolic syndrome (MetS), with and without diabetes mellitus (DM) and pre-existing CVD

NHANES: 199904NHANES II 197680 Follow-Up Study*

Source : NCHS and NHLBI.Source: Malik et al.(10) *Average of 13 years of follow-up.

Chart 7B: Hospital discharges for heart failure by sex

United States: 19702004

Note: Hospital discharges include those inpatients discharged alive, dead or status unknown. Source: NHDS, NCHS and personal communication with NHLBI.

Hospital Discharges for HF

CHF Discharges

-----------In thousands------

MalesFemales

708074

7986

98102

107111

121113

75122131

123143

143152

157173

174203

80176224

182240

195243

208255

228303

85247310

274308

269336

277357

304339

90315386

360405

373449

394481

390484

95378494

377493

431526

438540

430532

00418581

444551

441529

471566

04524575

Chart 7C. Incidence of heart failure* by age and sex

FHS 19802003

* - HF based on physician review of medical records and strict diagnostic criteria.

Source: NHLBI.(10)

7010

7522

8057

85719

902,107

952,363

002,199

052,125

Chart 13A: Trends in heart transplants

UNOS: 19702005

Source: United Network for Organ Sharing (UNOS), scientific registry data.

est. cv oper. & proc

u.s. 1979-03 (000)

CatheterizationsOpen-HeartBypassPTCACarotid EndarterectomyPacemakers

`NH WhitesNH BlacksHispanics792991721145442

Males24.914.024.8803501971375544

Females27.011.919.28569030823010740

9010465013922666897

Chart 9A: Prevalence of high school students in grades 912 reporting current cigarette use951137722573419132136

by sex and race/ethnicity001318686519561124152

YRBS: 2005011314690516571128177

021463709515657134199

04129764642766498170

Chart 13B: Trends in cardiovascular inpatient operations and procedures

United States: 19792004

Source: MMWR.4 NH indicates non-Hispanic.

MenWomen

NH White24.120.4

NH Black23.920.2

Hispanic18.915

Asian17.811.3Source: NHDS. NCHS and NHLBI. Note: In-hospital procedures only.

American Indian or Alaska Native37.333.4

Chart 9B: Prevalence of current smoking for Americans age 18 and older by race/ethnicity and sexEST. COST OF CV DISEASES 2007

NHIS: 2004Coronary Heart Disease142.5

Stroke57.9

Hypertensive Disease63.5

Heart Failure29.6

Chart 14A: Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke

United States: 2007

Source: MMWR.1 NH indicates non-Hispanic.

1988-941999-022003-04

NH White206204202

NH Black204199197

Mexican American205202201Source: NHLBI

Chart 9C: Trends in mean total serum cholesterol among adults by race, sex and survey

NHANES: 198894, 199902 and 200304

Source: NCHS and NHLBI.

Note: Needs split scale.

1976-801988-941999-022003-04

White Males163163155156

Black Males171165166161

White Females170166163164

Black Females172174168161

Chart 9D: Trends in mean total serum cholesterol among adolescents ages 1217 by race, sex and survey

NHANES:1976-80,1988-94, 1999-02 and 2003-04


Note: Needs split scale.

MenWomen

Total Population32.032.0

NH Whites32.034.0

NH Blacks32.030.0

Mexican Americans39.031.0

Chart 9E: Age-adjusted prevalence of Americans age 20 and older with

LDL cholesterol of 130 mg/dL or higher by race/ethnicity and sex

NHANES: 200304


MenWomen

Total259

NH Whites269

NH Blacks167

Mexican Americans2813

Chart 9F: Age-adjusted prevalence of Americans age 20 and older with

HDL cholesterol under 40 mg/dL by race/ethnicity and sex

NHANES: 200304


NH WhiteNH BlackHispanic

Male46.938.239

Female30.221.326.5

Chart 9G: Prevalence of students in grades 912 who met currently recommended

levels of physical activity during the past 7 days by race/ethnicity and sex

YRBS: 2005

Note: Currently recommended levels is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day on 5 or more of the 7 days preceding the survey. Source: MMWR.1

Source:YRBS (4)

19942004

NH White Male26.418.4

NH Black Male34.227.0

Hispanic Male37.532.5

Asian/Pacific Islander Male25.020.4

Am. Indian/Alaska Native Male34.423.8

NH White Female28.321.6

NH Black Female45.733.9

Hispanic Female44.839.6

Asian/Pacific Islander Female31.524.0

Am. Indian/Alaska Native Female36.331.8

Chart 9H: Prevalence of leisure-time physical inactivity among adults age 18 and older by race/ethnicity and sex

BRFSS: 1994 and 2004

Source: MMWR.(11) NH indicates non-Hispanic.

MalesFemales

NH Whites15.28.2

NH Blacks15.916.1

Hispanics21.312.1

Chart 9i: Prevalence of overweight among students in grades 912 by sex and race/ethnicity

YRBS: 2005

Source: BMI 95th percentile or higher by age and sex of the CDC 2000 growth chart. MMWR.(2) NH indicates non-Hispanic.

MenWomen

65-749.24.7

75-8422.314.8

85-9443.030.7

1960-621971-741976-801988-942001-2004

Men10.712.212.820.630.2

Women15.716.817.126.034.0

Chart 9J: Age-adjusted prevalence of obesity in Americans ages 2074 by sex and survey

NHES 196062; NHANES: 197174, 197680, 198894 and 200104

Note: Obesity is defined as a BMI of 30.0 or higher. Source: Health, United States, 2006; Unpublished data, NCHS.

6-1112-19

1971-744.33.6

1976-806.66.4

1988-9411.611.0

2001-200418.716.3

Chart 9K: Trends in the prevalence of overweight among U.S. children and adolescents by age and survey

NHANES: 197174, 197680; 198894 and 200104

Source: Health, United States, 2006. Unpublished data. NCHS.

NH WhitesNH BlacksMexican Americans

Men69.89.9

Women4.512.211

Chart 9L: Prevalence of physician-diagnosed diabetes in Americans age 20 and older by race/ethnicity and sex

NHANES: 19992004

NCHS and NHLBI


Less than high school7.512.010.1

High school5.69.76.0

More than high school4.29.89.8

Chart 9M. Prevalence of Non-Insulin-Dependent (Type 2) Diabetes in Americans Age 18+

by Education, Race/Ethnicity and Years of Education

NHANES: 1999-2004


Sheet1

10.712.212.820.630.2

15.716.817.12634

1960-62

1971-74

1976-80

1988-94

2001-2004


Sheet2

4.36.611.618.7

3.66.41116.3

1971-74

1976-80

1988-94

2001-2004


Sheet3

185.303214.49

190.125240.37

194.834252.488

207.11257.35

221.391275.644

236.69317.084

258.645326.377

287.202327.978

281.616347.436

288.585374.508

312.253351.142

324.63397.288

369.68417.005

383.856455.757

403.565490.614

395.02491.788

383.917496.515

381.013496.109

436.463530.027

442.23547.189

433.785540.992

421.896585.791

446.166553.626

442.772530.311

495.774597.144

524575

Male

Female

Years

Discharges in Thousands

299172114795442

350197137805544

6903082308510740

10465013922666897

1137722573419132136

1318686519561124152

129764642766498170

Catheterizations

Open-Heart

Bypass

PCI

Carotid Endarterectomy

Pacemakers

Years

Procedures in Thousands

24.927

1411.9

24.819.2

Males

Females


24.123.918.917.837.3

20.420.21511.333.4

NH White

NH Black

Hispanic

Asian

American Indian or Alaska Native


46.938.239

30.221.326.5

NH White

NH Black

Hispanic

Sex and Race/Ethnicity


151.6

62.7

66.4

33.2

Billions of Dollars

0.30.2

21.5

7.25.2

11.612.4

Men

Women


206204202

204199197

205202201

1988-94

1999-02

2003-04

Mean Serum Total Cholesterol

2.64.34.86.310.917

5.37.88.611.516.728.1

14.417.121.126.13044.1

No MetS or DM

MetS w/o DM

MetS w/DM

DM only

Prior CVD

Prior CVD and DM

Deaths/1,000 Person Years

MBD0006B35A.xls

Chart6

3232

3234

3230

3931

Men

Women


OVERWT

1960-621971-741976-801988-942001-2004

Men10.712.212.820.630.2

Women15.716.817.126.034.0

Age-Adjusted Prevalence of Obesity* in Americans Ages 20-74 by Sex and Survey

NHES and NHANES: 1960--62, 1971--74, 1976--80, 1988--94 and 2001-2004

Source:Health US, 2004.

Obesity is defined as BMI of 30 plus.

&A

Page &P

OVERWT

1960-62

1971-74

1976-80

1988-94

2001-2004


cholchild

Estimated Percentage of Children With Serum Cholesterol of 170 mg/dl or More, United States

WhiteBlack

Males 0-9 Years2940

Females 0-9 Years3350

Males 10-19 Years2534

Females 10-19 Years2941

Estimated Percentage of Children With Serum Cholesterol of 170 mg/dL

or More, United States

Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex and Race and Survey

NHANES:1976-80,1988-94, 1999-02 and 2003-04

1976-801988-941999-022003-04

White Males163163155156

Black Males171165166161`

White Females170166163164

Black Females172174168161

`

cholchild

&A

Page &P

White

Black


diabetes

1976-80

1988-94

1999-02

2003-04

Mean Total Blood Cholesterol

Strokerace


Men6.710.711.0

Women5.613.210.9

Age-Adjusted Prevalence of Physician-Diagnosed Diabetes in Americans Age 20 and Older by Sex and Race/Ethnicity

NHANES: 1999-2004

WhitesBlacksMexican Americans

122.95.46.4

Prevalence of Non-Insulin-Dependent (Type 2) Diabetes in Women Ages 25-64

by Education and Race/Ethnicity

NHANES III: 1988-94

OLD

Winkleby et al.


Less than high school7.512.010.1

High school5.69.76.0

More than high school4.29.89.8

Prevalence of Non-Insulin-Dependent (Type 2) Diabetes in Americans Age 18+

by Education, Race/Ethnicity and Years of Education

NHANES: 1999-2004

`

NCHS and NHLBI.

&A

Page &P

Strokerace

000

000

NH Whites

NH Blacks

Mexican Americans


Hdl&Ldl

000

000

000

000

Whites

Blacks

Mexican Americans

Years of Education


smokhschool

000

000

000

Less than high school

High school

More than high school


Metsyndr.

Relative Risk of Deaths due to StrokeCompared to Non-Hispanic Whites, by Race/Ethnicity and Age Groups, U.S., 1997

Non-Hispanic BlacksAmerican Indians/ Alaska NativesAsian/Pacific IslandersHispanics

35-444.01.91.31.3

45-543.91.31.31.3

55-643.01.51.41.2

65-741.90.91.10.9

75-841.20.81.00.6

85+0.90.40.70.5

Risk for Stroke Mortality Among Racial/Ethnic Groups Compared With Non-Hispanic Whites,

by Age Groups

United States: 1997

Metsyndr.

000000

000000

000000

000000

35-44

45-54

55-64

65-74

75-84

85+

Race/Ethnicity

Relative Risk

PhysicAct.

Estiamted % of Americans Age 20 and Over with High-Risk LDL-Cholesterol of 130 mg/dL or More by Race and Sex

MenWomen

Total Population32.032.0

NH Whites32.034.0

NH Blacks32.030.0

Mexican Americans39.031.0

Age-Adjusted Prevalence of Americans Age 20 and Older With

LDL-Cholesterol of 130 mg/dL or Higher by Race/Ethnicity and Sex

United States: 2003-04

MenWomen

Total259

NH Whites269

NH Blacks167

Mexican Americans2813

Estimated Age-Adjusted (2000) Prevalence of Adults Age 20 and Over With

HDL-Cholesterol Under 40 mg/dL by Race and Sex

United States: NHANES 2003-2004

PhysicAct.

Men

Women


smokmf

Men

Women


NHANESrf

`NH WhitesNH BlacksHispanics

Males24.914.024.8

Females27.011.919.2

Prevalence of High School Students in Grades 9-12 Reporting Current Cigarette Use

Within the last 30 days by Race/Ethnicity and Sex

YRBS: 2005

&A

Page &P

NHANESrf

00

00

00

Males

Females


oweight hs

CHD MortalityCVD MortalityTotal Mortality

No MetS or DM2.65.314.4

MetS w/o DM4.37.817.1

MetS w/DM4.88.621.1

DM only6.311.526.1

Prior CVD10.916.730.0

Prior CVD and DM17.028.144.1

Total Mortality Rates in US Adults Age 30-75, with Metabolic Syndrome, With and Without Diabetes and Pre-Existing CVD

NHANES1976-80 Follow-Up Study

oweight hs

000000

000000

000000

No MetS or DM

MetS w/o DM

MetS w/DM

DM only

Prior CVD

Prior CVD and DM

Deaths/1,000 Person Years

RFNHANES

% of high school students who participated in vigorous or moderate physical physical activity in past 7 days

NH WhiteNH BlackHispanicBMI

BackVisceral ATSubcutaneous ATFrontIntra-abdominal (Visceral) FatThe dangerous inner fat!

The Metabolic SyndromeInsulinResistanceHypertensionType 2 DiabetesDisorderedFibrinolysisComplexDyslipidemia TG, LDLHDLEndothelialDysfunctionSystemicInflammation

Athero-sclerosis

VisceralObesityAdapted from the ADA. Diabetes Care. 1998;21:310-314; Pradhan AD et al. JAMA. 2001;286:327-334.

ATP III: The Metabolic Syndrome**Diagnosis is established when 3 of these risk factors are present.Abdominal obesity is more highly correlated with metabolic risk factors than is BMI. Some men develop metabolic risk factors when circumference is only marginally ; ** new ADA guideline for impaired fasting glucose >=100 mg/dlincreased.Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. 2001, Professional Postgraduate Serviceswww.lipidhealth.org

Diagnostic Criteria forGlycemic AbnormalitiesFPG=Fasting plasma glucose, PG=Plasma glucose, OGTT=Oral glucose tolerance testTo convert mg/dL to mmol/L multiply mg/dl by 0.055The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2001;24:S5-S20American Diabetes Association. Diabetes Care 2010;33:S11-61

Cardiovascular Disease (CVD) and Total Mortality: US Men and Women Ages 30-74(age, gender, and risk-factor adjusted Cox regression) NHANES II Follow-Up (n=6255)(Malik and Wong, et al., Circulation Sept 8, 2004)* p

Causes of Mortality in Patients With Diabetes Diabetes is considered a risk equivalent for coronary heart disease

Annual CHD Event Rates (in %) by Calcium Score Events by CAC Categories in Subjects with DM, MetS, or Neither Disease(Malik and Wong et al., Diabetes Care 2011)Coronary Heart DiseaseCoronary Artery Calcium ScoreACCF/AHA 2010 Guideline: CAC Scoring for CV risk assessment in asymptomatic adults aged 40 and over with diabetes (Class IIa-B)

Chart1

0.10.20.4

0.40.81.5

1.32.11.9

2.23.54

Annual CHD Event Rate

Neither MetS/DM

MetS

DM

Sheet1

Neither MetS/DMMetSDM

00.10.20.4

1-990.40.81.5

100-3991.32.11.9

400+2.23.54

To resize chart data range, drag lower right corner of range.

Total Cholesterol Distribution: CHD vs Non-CHD PopulationCastelli WP. Atherosclerosis. 1996;124(suppl):S1-S9.1996 Reprinted with permission from Elsevier Science.35% of CHD Occurs in People with TC

Low HDL-C Levels Increase CHD Risk Even When Total-C Is Normal (Framingham)HDL-C Recommendations: >50 mg/dl women, >40 mg/dl men, optimal HDL-C >60 mg/dl.Castelli WP et al. JAMA 1986;256:2835283802468101214< 4040495059 60< 200230259200229 260HDL-C (mg/dL)Total-C (mg/dL)14-y incidence rates (%) for CHD11.2411.9112.5011.916.564.679.055.534.854.153.772.782.063.8310.76.6

Adapted from Ballantyne CM. Am J Cardiol. 1998;82:3Q-12Q.Primary and Secondary Prevention Trials With Statins

National Cholesterol Education Program, Adult Treatment Panel III, 2001. JAMA 2001:285;24862497NCEP ATP III: LDL-C Goals

Lipid Management Goal: Persons with Pre-existing CHD

LDL-C should be less than 100 mg/dL

Further reduction to LDL-C to < 70 mg/dL is reasonable*Non-HDL-C = total cholesterol minus HDL-CIf TG >200 mg/dL, non-HDL-C should be < 130 mg/dL*

P. Ridker

hs-CRP Adds to Predictive Value of TC:HDL Ratio in Determining Risk of First MITotal Cholesterol:HDL RatioRidker et al, Circulation. 1998;97:20072011.hs-CRPRelative Risk

4-Year Progression To Hypertension: The Framingham Heart Study(

Diabetes Prevention Program: Reduction in Diabetes Incidence

The 2010 Dietary Guidelines23 Recommendations Jan 31, 2011

Enjoy your food, but eat less.Avoid oversized portions.Make half your plate fruits & vegetables.Switch to fat free or low fat milk (1%).Compare sodium in foods e.g. soup, bread & frozen meals & choose foods with lower numbers.Drink water instead of sweetened beverages. www.dietaryguidelines.gov

Eight Diet/lifestyle RecommendationsAmer Heart Assoc: 2006 1. Balance kcal intake & physical activity to achieve optimal body weight.

2. Consume a high fiber diet rich in fruits & vegetables, legumes & whole grains.

3. Consume fish, especially oily fish at least 2x /wk.

AHA 2006 Eight Diet & Lifestyle Recommendations 4. Limit saturated fat

AHA 2006 Eight Diet & Lifestyle Recommendations5. Minimize sugar in food & beverages

6. Choose foods with little or no salt(2011 recommendation: sodium intake

Reading Food LabelsBe wary of healthier foods that advertise containing whole grainsbut that may also significant amountsof sugar and trans fat (e.g., partially hydrogenated oils)Always check dietary fiber, fat, and sugar content per serving

Choose whole or multigrain bread, check dietary fiber content

Encourage Increased Physical ActivityBrisk walking is an ideal physical activity for those without orthopedic issuesWalking uses the patients increased body weight to increase energy expenditurePedometers provide daily feedback - 10,000 Steps Per Day

Mylifecheck.heart.org

Age-standardized prevalence estimates for poor, intermediate and ideal cardiovascular health for each of the seven metrics of cardiovascular health in the AHA 2020 goals, among US adults >20 years of age, NHANES 2005-2006 (baseline available data as of January 1, 2010).2010 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2010 Fewer than 1% of US adults are at ideal levels for all 7 measures of cardiovascular health!

Chart1

24.53.272.2

33.832.933.2

31.723.245.2

76.822.90.24

1538.446.6

17.141.241.7

8.230.461.4

Poor

Intermediate

Ideal

Percentage

Sheet1

PoorIntermediateIdeal

Current Smoking24.53.272.2

Body Mass Index33.832.933.2

Physical Activity31.723.245.2

Healthy Diet Score76.822.90.2

Total Cholesterol15.038.446.6

Blood Pressure17.141.241.7

Fasting Plasma Glucose8.230.461.4

UCI Preventive Cardiology ProgramOCs only multidisciplinary cardiovascular prevention programPatients meet regularly with cardiologist, dietitian, and exercise physiologistFocus on cardiac risk factor reduction and weight loss through lifestyle modificationFor persons with and without prior heart disease who have one or more risk factorsSpecialized biomarker and imaging tests (e.g., calcium scan) are availableCall 714-456-6699

Thank You! For more information: www.heart.uci.edu or www.heart.orgEmail: Nathan D. Wong, PhD at: [email protected]

****2.03********************3*To measure waist circumference, 1) locate the upper hip bone and the top of the right iliac crest, 2) place the measuring tape in a horizontal plane around the abdomen at the iliac crest, 3) ensure that the tape is snug but does not compress the skin, 4) the tape should be parallel to floor, and 5) record the measurement at the end of a normal expiration.Men are at increased relative risk if they have a waist circumference greater than 40 inches (102 cm); women are at an increased relative risk if they have a waist circumference greater than 35 inches (88 cm).There are ethnic- and age-related differences in body fat distribution that may affect the predictive validity of waist circumference as a surrogate for abdominal fat.Heterogeneity of composition of abdominal tissues, in particular adipose tissue and skeletal muscle, and their location-specific and changing relations with metabolic factors and CV risk factors in different ethnic groups do not allow a simple definition of abdominal obesity that could be applied uniformly. In particular, Asians appear to have higher morbidity at lower cutoff points for waist circumference than do white Caucasians.

National Institutes of Health, National Heart, Lung, and Blood Institute, NHLBI Obesity Education Initiative, North American Association for the Study of Obesity. The practical guide to the identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication Number 00-4084. October 2000.Misra A, Wasir JS, Vikram NK. Waist circumference criteria for the diagnosis of abdominal obesity are not applicable uniformly to all populations and ethnic groups. Nutrition. 2005;21:969-976.*Circling back to the discussion of abdominal adiposity, data regarding waist circumference and diabetes illustrate its health impact. These are age-adjusted data from the Nurses Health Study, analyzing responses from 43,581 subjects who provided information on weight and body measurements in 1986. These subjects had no history of cancer, heart disease, stroke, or any type of diabetes. An 8-year follow-up in this population showed a strong positive association between waist circumference and the incidence of diabetes. At the far end of the spectrum, women with a waist circumference >38 inches had a diabetes risk of 22.4, relative to women in the normal waist circumference range of 126 mg/dl or (b) a two hour plasma glucose of >200mg/dl after a 75 gram oral glucose load. An International Committee recently added the hemoglobin A1C assay as an alternative diagnostic test, with a level 6.5% indicating diabetes and a level between 6.0 and 6.5% indicating high risk for progression to diabetes.

**Cardiovascular disease is the most common cause of death among patients with diabetes, according to data from death certificates. Heart disease accounts for approximately 55% of all deaths and cerebrovascular disease is responsible for another 10% of deaths. Acute diabetes-related complications are the next most common cause of death, accounting for 13% of deaths. Pneumonia/influenza, malignant neoplasms, and other causes account for the remaining deaths. Renal disease is not listed as a separate category, because dialysis and transplantation have made renal failure an uncommon immediate cause of death. However, cardiovascular disease is a common cause of death in patients on long-term dialysis.In patients with type 2 diabetes, the relative contribution of cardiovascular disease as a cause of death is greater in younger-age and younger-age-at-onset patients than in older-age and older-age-at-onset patients.

Geiss LS, et al. Mortality in non-insulin-dependent diabetes. In: Diabetes in America. 2nd ed. Bethesda, Md: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health; 1995:233-257. NIH Publication No. 95-1468.*Data from the Framingham Heart Study show the continuous relationship between risk of developing CVD over 8 years and levels of cholesterol.9 Other assumptions for this model are that the patient was a 40-year-old man, who was ECG left ventricular hypertrophy (LVH) negative, and with no glucose intolerance, and who was not a current smoker. As illustrated on this slide, the relationship between level of total cholesterol (TC) and CVD risk is graded and continuous. Risk is not confined to the upper centiles.9 9.Kannel WB. Importance of hypertension as a major risk factor in cardiovascular disease. In: Genest J, Koiw E, Kuchel O, eds. Hypertension. Physiopathology and Treatment. New York, NY: McGraw-Hill; 1977:888-910.*Slide 3. Total cholesterol distribution: CHD vs non-CHD populationIn the Framingham Heart Study, as many as one third of all coronary heart disease (CHD) events occurred in individuals with total cholesterol

New Concepts and Strategies for Prevention of Cardiovascular Disease Nathan D. Wong, PhD, FACC, FAHA...

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