- Email: [email protected]
Primordial Prevention of Cardiovascular Disease Risk Factors: Panel Summary
Preventive Medicine 29, S130–S135 (1999) Article ID pmed.1998.0438, available online at http://www.idealibrary.com on
Primordial Prevention of Cardiovascular Disease Risk Factors: Panel Summary Jeremiah Stamler, M.D.,* Stephen P. Fortmann, M.D.,† Robert I. Levy, M.D.,‡ Ronald J. Prineas, M.D., Ph.D.,§ and Grethe Tell, Dr.Philos., M.P.H.¶ *Department of Preventive Medicine, Northwestern University Medical School, Chicago, Illinois 60611; †Stanford University Medical School, Stanford, California 94305; ‡Wyeth-Ayerst Research, Philadelphia, Pennsylvania; §Department of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN; and ¶Research Centre for Health Promotion, Environment & Lifestyle, University of Bergen, 5020 Bergen, Norway
Jerry Stamler
I’d like first to try to put into context what we have been about these past 2 days. That context is twofold. First is the fact that in this country, and in many other industrialized countries, the flank of the coronary and cardiovascular epidemic has been turned. The U.S. figure is a 55% decline in coronary mortality since the peak in the mid-1960s, 70% in stroke, proving that this set of diseases is preventable. I dont think anyone challenges the fact that turning this flank has been achieved—in part—as a result of primary prevention, not just tertiary care for people already sick. The challenge we face is to maintain, extend—particularly to lower socioeconomic strata, and accelerate that trend in order to bring the epidemic to an end, that is, by early in the next century to bring our rates for coronary disease mortality down to those of Japan—e.g., in the early 1990s, age-standardized rates of about 50 and 25 per 100,000 for men and women, respectively, compared to about 225 and 120 for Americans [1]. That is a realistic goal. The key to this challenge is the strategy of primordial prevention of the risk factors themselves—and not “just’’ continuation—I deliberately put the word just in quotes—with a strategy that in general emphasizes primary and secondary prevention. That is the strategic emphasis in the Report of the National Heart, Lung, and Blood Institute (NHLBI) Task Force on Research on CV Epidemiology and Prevention [2]. This concept, that in order to end the epidemic it is necessary to move to a higher plane than before, has as its foundation the achievement to date; it is not a statement of desperation in the face of defeat. Rather it addresses the next important state of advance, based on the achievement to date—what is necessary to continue, maintain, and extend that achievement. Let me here note in saying
this that, as far as I know, nowhere in the world is there yet at the national level an actual policy commitment to primordial prevention of the risk factors. I dont think that such an explicit policy commitment exists anywhere, not, to the best of my knowledge, in the American Heart Association (AHA), the American College of Cardiology (ACC), the NHLBI, the National Institutes of Health (NIH), or the U.S. Department of Health and Human Services. I am convinced that getting policy commitments at the highest level is an essential step forward for public health. We must fight to register this as public policy, just as in 1970 in the Report of the Inter-Society Commission for Heart Disease Resources (ICHD) we registered population-wide primary prevention as the key strategic emphasis, set down its specific components, and stressed the importance of making available long term the necessary resources to accomplish this task [3]. The second aspect of the contest of our deliberations that I want to highlight is that primordial prevention of the risk factors is for all strata of the population—all socioeconomic, ethnic, and regional strata—beginning with all pregnant women. There is already enough confirmation of what Barker et al. first found to enable us to conclude that major risk factor status is influenced to a degree in utero. Thereafter, primordial prevention must relate to all postweaned infants, weaned, it is hoped, not from the bottle but rather from the breast because that is healthier from many points of view, ranging from type of ingested fat and amount of salt consumed to immunologic mechanisms. It continues with primary and secondary school children and with youths and young adults as they make the transition— decisive in terms of the mass development of high-risk status—from youth into middle age. As we heard here,
S130
0091-7435/99 $30.00 Copyright q 1999 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
PRIMORDIAL PREVENTION OF CVD RISK FACTORS
there are now extensive data on that. Clearly, for several key reasons the notion in certain quarters to forget about younger people, men and women, is wrong. In terms of content, primordial prevention encompasses all aspects of lifestyle. It means helping to achieve cohorts with 40, 60, or 80% of the population at low risk—instead of the less than 10% nowadays—with optimal serum cholesterol and blood pressure levels, not smoking, not obese, not diabetic. We can help to create larger and larger cohorts like this only by addressing all aspects of lifestyle, doing this concurrently and continuously. And I agree very much with what Steve said, diet and exercise are crucial in this regard. It is often said by some public health people that achieving progress in reducing prevalence of smoking in the population is the single most important practical way to advance public health. Not quite entirely valid; they are making a good point, but in a one-sided way in my judgment. It certainly is a very important way, but in my judgment its not the single best way. The roots of this epidemic, as anyone who ever produced atherosclerosis or hypertension in experimental animals knows, are first and foremost nutritional. Hence it seems to me to be a useful function of this closing Summary Panel to emphasize two decisive nutritional specifics given little attention over these 2 days; first, the important role—in producing clinically significant severe atheroslerosis at epidemic levels—of habitual excessive dietary cholesterol intake and second, the important role—in producing population-wide adverse blood pressure levels—of habitual excessive salt intake. To implement primordial prevention, we need sustained, effective, specific societal efforts, including a focus on lower socioeconomic strata, to resolve the social and economic problems that stand in the way of achieving the comprehensive changes in lifestyles required. Here I reemphasize the point that Grethe made, and this is my last specific point, that we need to get across much more about foods. We talk in our meetings mostly about nutrients, but people buy foods. They buy them in fast food establishments, grocery stores, cafeterias, vending machines, supermarkets. For all people, we need to make clear what we are talking about: more whole grains, beans, fruits and vegetables, fat-free dairy products, egg whites without the yolks, fish and shellfish, lean poultry, and lean meat. Those are the emphases. Less processed fast food means fewer processed main dishes, mostly high in calories, salt, and fat; less high-fat meat generally, fewer high-fat commercial baked goods; fewer high-fat dairy products; few or no egg yolks; less of the visible fats, to get total fat down to under 30% or even under 25% of calories. Alessandro Menotti gave us brief insight into progress in Italy along these lines. We also need less loading of foods with salt by commercial food processors. Seventyfive percent of ingested salt comes from commercially
S131
processed foods; salt is a major food additive. We need to convey this comprehensive message about foods to the people, about enjoying and enhancing the pleasure of eating in these modified ways, based on the best aspects of the eating styles of all our ethnic strata. What is needed is a new policy commitment to this higher level effort, a la the ICHD report and AHA and NHLBI reports of 2 decades ago. And what is needed also are the resources to implement this and a hearty rebuff to the notion that economic scarcities make this impossible. I get weary reading in medical journals the litany about scarcities, that the demands of the people for medical care are boundless, our resources are limited, rationing is essential, etc., etc. Two points on this in closing: One—in the middle of the 19th century in this country and Britain, in the face of horrendous health conditions and in societies at a much lower level of economic and technologic development than now, movements powered largely by the laity created modern public health, mobilized resources to overcome the problems and the resistance of special interests, did the job, and changed the whole scene. Two—if resources could be mobilized then, the idea cannot be valid that there is nowadays a true scarcity of resources in our much wealthier and more advanced countries. The nub of the problem is persistently aberrant national priorities, first and foremost hundreds of billions endlessly spent on maintenance of a military–industrial complex and endless postponement of any “peace dividend.’’ A peace dividend is needed for the health of the people. Thank you. REFERENCES 1. Reeder B, Chockalingan A, Dagenais G, MacLean D, Nair C, Petrosovits A, Shuaib A, Skwarchuk D, Taylor G, Wielgosz A, Wilson E, in collaboration with Health Canada, Laboratory Center for Disease Control, Statistics Canada, University of Saskatchewan. Heart disease and stroke in Canada, Ottawa: Heart and Stroke Foundation of Canada, 1997:9. 2. Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases. National Heart, Lung, and Blood Institute Report of the Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases. Bethesda (MD): U.S. Department of Health and Human Services, National Institutes of Health, 1994. 3. Inter-Society Commission for Heart Disease Resources, Atherosclerosis Study Group and Epidemiology Study Group. Primary prevention of the atherosclerotic diseases. Circulation 1970;42:A55–95. Steve Fortmann
Thank you, Jerry. Let me also add my thanks to Russell Luepker for including me in the program and to Henry Blackburn for the leadership he has provided to our enterprise in cardiovascular epidemiology and prevention for all of the years that I have been involved in it. While I never attempted to make the transition
S132
STAMLER ET AL.
from California to Minnesota, the influence was nevertheless strong from the distance. I want to emphasize, first, some things that have been left unstated perhaps because of the audience. I think we have not stated explicitly that primordial prevention is indeed possible. There is no obligatory level of atherosclerosis in a population; adult blood pressure does not normally rise with age and neither does serum cholesterol or weight. Second, the causes of epidemic cardiovascular disease are pretty well understood and there is much to do with the knowledge that we now have. It has been one of our assumptions in this conference that diet and physical activity are two of the most fundamental behaviors for primordial prevention and, while we have much to learn about them, there is also much we can do now. I want to highlight two other themes that came out of the Conference. One is the social and community aspects of primordial prevention: Drs. Tyroler, James, Mittlemark, and Kaplan all touched on this. We cannot view the primordial prevention of cardiovascular disease as an isolated problem, differentiated from other problems in society, differentiated from general educational levels, other disease problems, the cultures that we are working with, the networks within communities, etc. One of the most important risk factors for cardiovascular disease is educational level. This means that anything that is done to improve the general educational level is liable to improve cardiovascular disease rates. I appreciate that there is limited cause and effect proof for that statement, but I think we would accept its truth. Yet, political efforts to improve education in this country almost never mention that health benefits would likely come from such improvements. We also cannot view cardiovascular risk in isolation for the high-risk subgroups in the United States who also face violence, economic underdevelopment, and especially adverse dietary patterns. We have been reminded here of the importance of culture as a concept in approaching these groups and also the importance of making these approaches community-based, coming from the communities. Second, the challenges of primordial prevention are never more salient than when we consider exercise, on which we had little impact in the Five-City Project, certainly much less than we would have hoped. Physical inactivity is woven into the fabric of this country, in transportation, food delivery, food storage, etc., so intimately as to be daunting to the health activist. Even those of us who are the most active achieve that status by grafting some exercise on an otherwise sedentary existence. We cannot easily walk to the grocery store if there are no sidewalks and we have to transport enough food to fill the freezer at home. Neither can the
inner city dweller, if there is no store in the neighborhood. Here primordial prevention requires that we address city planning functions, perhaps we need health impact statements as well as environmental impact statements for urban planning. This is an inopportune time in the United States to suggest another layer of bureaucracy or regulation. Yet again, I think we might find a very receptive audience if we began to point out to the public the health impacts of some of these decisions. We need to understand better the characteristics of the communities in which we have observed improving health status without any help from any of us. Dr. Menotti pointed out how much change in Italy has been achieved with few organized efforts. When the right people know what needs to be done, they do not need academic activists to help them out. I must also mention the role of the media (being from Stanford). The media may have played a role in Italy, as Dr. Menotti reminded us, and Dr. Finnegan showed us very interesting data on the role of the media in this country. It may be that the U.S. media can achieve a lot of health education even at the level that it will sustain on its own (with some coaxing and help from public health advocates and agencies). This may have much to do with the salience of the information provided. In the Five-City Project we ended up estimating (I wont attempt to give you a standard error) that we achieved about 5 hours of education per person per year to the average individual in Monterey and Salinas. That compares to the average Americans exposure to 292 hours per year of television advertising alone. Yet, the message got out, people knew about the project, and knowledge levels, at least, changed. We wont argue here about the behavioral effects, but certainly the message was heard and I think that is partly because the population, in fact, is ready to receive it. I will close by commenting on funding for health promotion efforts and the relationship of prevention with the medical care system. I do not label it a health care system, because it is not such. However, primordial prevention, as any sort of prevention, needs a sustained effort. If you think about it, most of the decline in tobacco smoking in this country has been the result of a 30-year information campaign that did achieve behavior change. We have to take a long view of primordial prevention. I think public health agencies are the appropriate place to address these issues but at present they are overburdened with indigent care, underappreciated, and poorly funded. This time of turmoil in the medical care system is an opportunity, I hope, for closing the unnatural distance between the medical care and public health systems in the United States. We need closer cooperation to make progress. Dr. Terris comments about taxing medical care expenditures to provide sustainable funding are most salient. It would take a very small tax on the enormous monies expended
S133
PRIMORDIAL PREVENTION OF CVD RISK FACTORS
for medical care to provide ample funding for both public health and biomedical research. This brings us to the undeniable fact that we must become better at political advocacy to address primordial prevention;. The tobacco control effort in this country is a good example of how public health efforts can be augmented significantly by advocacy. Thank you again, Jerry and colleagues. Grethe Tell
Thank you, Jerry. I would like to thank Russell Luepker for inviting me to be on this panel. Its an honor to have been invited and also somewhat humbling trying to add to this stimulating conference honoring one of my great mentors. I began my epidemiologic training at the division of Epidemiology when I came here from Norway in 1981. I spent 5 years in the division under Henry’s leadership and Russell’s tutorship, 5 years that have meant a lot to me. Thank you. I would like to start by commenting on what was mentioned about social inequalities by a few of the speakers during the conference. Social inequalities are often accompanied by health inequalities. Much attention has been devoted to fairness, equality, and access to such rights as voting, economic security, housing, and jobs. We now need to extend this attention, this battle, to include equal opportunity to healthy living. We, as scientists, need to become more politically active and help make healthy living a political issue. Epidemiologists can contribute to the policy-making process by providing both their data and their specific expert insights; we need to get messages across, to those who need them the most, that it is their right to have a healthy life. How do we get these messages across? During this conference we have heard several suggestions about how to proceed, at least on how to start the process. George Kaplan talked about our obligation to influence macroeconomics, especially with regard to implications for tobacco use. Sherman James pointed out the need to be aware of cultural values and beliefs and to be better students of culture. Access to resources, forming community-based partnerships, and involving the media are also important. Cheryl Perry and Maurice Mittelmark emphasized the importance of social influences. We must act on all these levels in interdisciplinary teams. I believe this is one of the most important messages we have heard at this conference—the need to be interdisciplinary in our approach, to make people aware of their right to healthy living, to make public policy be more responsive to the demands of the people themselves, and to instigate diffusion with a political and social focus. Unfortunately, the list of speakers at this otherwise excellent conference does not include any representatives from the newly independent states of the former Soviet Union. We know that cardiovascular diseases
and their risk factors are highly prevalent in that region, and pollution, economic conditions, and stress all increase the urgency for more effective preventive measures in the new states of Eastern Europe. I would like to end my comments with a few words about diet. This morning Sherman James proposed that we probably should focus much attention on smoking and physical activity intervention because that’s where we are most likely to achieve better results. Although I to a large extent agree, a focus on diet for the primordial prevention of cardiovascular diseases continues to be warranted. Clearly, there is much yet to learn about the role of diet in primordial prevention. Cheryl Perry pointed out the high fat intake among adolescents in Minnesota. I lived in North Carolina for 8 years and I’m familiar with the traditional North Carolina diet, extremely high in fat and a large contributor to the high prevalence of obesity, especially among women. Similarly, the contemporary diet in Eastern Europe is often unhealthy with too much fat and too few fruits and vegetables. We dont know enough about the determinants of dietary habits. While there is an abundance of descriptive studies reporting that people eat so-and-so many units of various nutrients, little is known about why people eat what they eat. We need to focus our research not only on the nutrients, but also on the foods that people eat and find out why people eat what they eat. There are, in the United States, subgroups of this population that are in complex ways at risk for nutrition-related diseases—not only those caused by too much fat or energy, but also diseases caused by too little of certain nutrients. It is time to move beyond the fat and cholesterol issue and expand our horizon about causes of cardiovascular diseases. The recent focus on homocysteine as a “new’’ risk factor is illustrative, and recently intake of folic acid has been related to homocysteine, as well as to cardiovascular and other chronic diseases. We need to focus on other vitamins, antioxidants, and minerals and trace elements. I think we need more research on why young women eat what they eat, or why they dont eat. Considering the relatively high prevalence of eating disorders among adolescent girls, we need to be careful when advising this group to reduce their fat intake. Finally, we need more research on how to avoid weight gain after smoking cessation, the reason many women refuse to quit smoking. Enhanced attention to these contemporary challenges in public health nutrition can contribute greatly to primordial prevention. Thank you. Bob Levy
Thank you. I feel a little bit like the prodigal son who has been away for at least a short period of time. Others have talked about their personal involvement. Let me just say that Jerry Stamler and Henry Blackburn began
S134
STAMLER ET AL.
to teach me epidemiology when I was appointed as a lipid expert to the Data and Safety Monitoring Committee of the Coronary Drug Project some 30 years ago and they have been teaching me ever since. I also was fortunate enough to have been a participant at the WHO meeting that authored the first document on the primary prevention of coronary disease. Both Dr. Stamler and Dr. Blackburn played a major role at that meeting. As I look and listen and react over the past day and a half, I am impressed with the fact that the cup is half empty and half full. Nothing has changed, and much has changed. We see that the same risk factors, even the so-called new ones, are really not new, they have just been rediscovered. We see the same issues, primary versus secondary, the public health approach versus the high risk approach. We see the concepts that were talked about at the WHO meeting on primary prevention continuing to boil and come forward. It was said at that time that the representatives from developing countries in Africa and Asia wanted everything we had, including heart disease and stroke. As I sit here today, I realize that they are on the way to obtaining these things unless some things change. We see the same villains, the tobacco lobby, indifference, focus in the medical area on acute care, poverty, lack of education, lack of incentives, and the media that can be very helpful but can also be villains. I am also impressed, however, that much has changed. We have better genetic and environmental epidemiologic tools, certainly the power of the computer sciences gives us the ability, not only to analyze data, but to transmit it worldwide in an instant. The database is even greater and immensely more persuasive than it was just 10 or 15 years ago, both on the identity of the risk factors and the effect of risk factor change on the disease we are talking about, coronary heart disease. There is a massive credible body of evidence now that has been replicated, as well as a large number of reports on how to accomplish risk factor change. We have greater experience and more knowledgeable practitioners in demonstration and education, a new cadre of people who are articulate workers in the field of coronary disease prevention. I am impressed with the remarkable consensus that has been presented here over these 2 days on what the problems are and what needs to be done. I am also impressed, in part, from my vantage point now in industry, that health care is itself in transition. Folks talk about managed care as if it was one thing, but its many things all struggling for center stage. Certainly cost containment is one element here and I can’t help but think about the number of times I ended my presentations in the past with the fact that prevention of disease was the most cost-effective means we have available.
We have questions right now about the future of the individual health care provider, the academic health center, even the role of the government in health. To me the time seems right, and perhaps it has already begun in Victoria [1] or Catalonia [2], to discover, or rediscover, the power and potential of an efficient coordinating structure on an effort, this time focused on all of prevention, primordial through secondary. A major focus would be to sustain the proactivity that I have heard and seen, with the AHA–ACC combined meeting published just recently with others in prevention, to capture the minds, the attention, the interest of new players, new players in government and new players in managed care. As I sat and listened over these 2 days, I thought about the fact that the time was right to go forth, much as the National High Blood Pressure Education program did over 20 years ago. What did that require? It required political activism by people like Mary Lasker who wouldnt take “no’’ for an answer. It required receptors in government, and there is no better time to find receptors in government than during an election year. It required willingness of parties to get together, to coordinate, to share, to leverage resources. When you look at how much each participating group spent in the National High Blood Pressure Program, it was pennies. When you look at the effect of the program with all the groups together, it had a major, invaluable impact. The National High Blood Pressure Education Program, when it started, had three parts for its base. One was research, and it is quite clear there is still much that we need to know. Another part was education, both public and private. A third part was demonstration. All this clearly needs to be part of any current effort, an effort that certainly should be national and then, clearly, global. The National High Blood Pressure Education Program worked because it included all of the major players, the voluntary health societies, the health care providers and users, government and industry, and minority and majority representatives, and it used all routes and avenues, including the legislative arena and the media. All this could be done now. The time is right. What one needs is some leadership to rekindle the effort and, I must say, if I was disheartened at all during these 2 days, it was when I realized that in some of our accomplishments, reinoculation or inoculation is vitally important and we are beginning to see a recidivism that needs to be prevented. I think that if and when we can get people together to go forth in a coordinated approach, it would be a fitting tribute to the careers of the gentleman sitting to the right of me, Dr. Stamler, and Henry Blackburn as well. If one does not go forward at this time, perhaps because of a shortage of leadership, I still think that
PRIMORDIAL PREVENTION OF CVD RISK FACTORS
one has put together an incredible legacy of solid evidence and I’m truly impressed with the ardor, capability, and capacity of the students and disciples of Henry Blackburn, and suggest that if we dont go forth now, we will go forth in the future, but the time is right now. REFERENCES 1. Advisory Board, First International Heart Health Conference, The Victorial Declaration. Victoria, British Columbia. 2. Advisory Board, Second International Heart Health Conference, Barcelona, May 28–June 1, 1995. The Catalonia Declaration: Investing in Heart Health. Barcelona: Generalital de Catalunya, Autonomous Government of Caldonia, 1995. Ron Prineas
Jerry, thanks very much. As we have gone through this we have heard repetition of themes from all of the presentations in the past day and a half and we need to summarize the major points. We have been presented with lists of barriers to primordial prevention and presenters have attempted to delineate what needs to be done to lead us to primordial prevention. How we finally achieve primordial prevention still remains problematic. Again and again, poor education and low income have been reiterated as major barriers. To make changes there we need social engineering on a scale that we probably dont know how to do very well in this country. One of the things that has remained with us, if you look back through the history of this country or any Western country, is that we have always had poverty and we’ve always had lack of education. It is time that poverty and lack of education are engaged by the prevention community. It becomes more hopeful if we look globally and try to think about solutions for countries like India (heard about at this conference), which is trying to avoid the importation of bad habits from more developed countries. The shared label policy has been particularly emphasized from the presentations this morning, and it is clearly a very important goal.
S135
If, like Grethe, I can single out a major risk factor that has been neglected, it is obesity, particularly in this country and other Western countries, despite decreases in smoking, blood pressure levels, serum cholesterol levels, and dietary intake of fat. Obesity continues to increase in prevalence and the intervention/prevention for that includes not only diet, but also exercise. As I’m talking about diet, we probably need to rethink the macronutrient levels that we aim for and I suggest that the goals for Healthy People 2000 be looked at again and that new targets be set. We really are very bold talking about primordial prevention when we are still doing a less than optimal job with primary prevention and secondary prevention. But having said that, we started primary prevention before we carried out secondary prevention very well, despite which we have had some very large successes, so it shouldn’t prevent us from initiating efforts for primordial prevention now. There is a continuum that has been mentioned many times in the past day and a half: in order to have primordial prevention, we require the optimum social structure in which the good habits of children are nurtured and affect their behaviors as they grow old. This cannot be readily achieved in the presence of high-risk factors and disease among their parents and in the rest of the community. So we really do need to have primordial prevention, primary prevention, and secondary prevention, all going on togther. Other preventive strategies need also be considered. Whenever we have been able to achieve ‘‘passive’’ prevention in public health, such as good sanitation or fluoridation of the water supply, we have been successful in disease. Correspondingly, fortification of foods could become an important primordial preventive measure. Folic acid and antioxidants are possibilities for consideration. I don’t think very much has been said about that in the past day and a half. Clearly the challenges of primordial prevention are multiple and complex—but the rewards from progress in meeting them are likely to be vast.
Primordial Prevention of Cardiovascular Disease Risk Factors: Panel Summary Jeremiah Stamler, M.D.,* Stephen P. Fortmann, M.D.,† Robert I. Levy, M.D.,‡ Ronald J. Prineas, M.D., Ph.D.,§ and Grethe Tell, Dr.Philos., M.P.H.¶ *Department of Preventive Medicine, Northwestern University Medical School, Chicago, Illinois 60611; †Stanford University Medical School, Stanford, California 94305; ‡Wyeth-Ayerst Research, Philadelphia, Pennsylvania; §Department of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN; and ¶Research Centre for Health Promotion, Environment & Lifestyle, University of Bergen, 5020 Bergen, Norway
Jerry Stamler
I’d like first to try to put into context what we have been about these past 2 days. That context is twofold. First is the fact that in this country, and in many other industrialized countries, the flank of the coronary and cardiovascular epidemic has been turned. The U.S. figure is a 55% decline in coronary mortality since the peak in the mid-1960s, 70% in stroke, proving that this set of diseases is preventable. I dont think anyone challenges the fact that turning this flank has been achieved—in part—as a result of primary prevention, not just tertiary care for people already sick. The challenge we face is to maintain, extend—particularly to lower socioeconomic strata, and accelerate that trend in order to bring the epidemic to an end, that is, by early in the next century to bring our rates for coronary disease mortality down to those of Japan—e.g., in the early 1990s, age-standardized rates of about 50 and 25 per 100,000 for men and women, respectively, compared to about 225 and 120 for Americans [1]. That is a realistic goal. The key to this challenge is the strategy of primordial prevention of the risk factors themselves—and not “just’’ continuation—I deliberately put the word just in quotes—with a strategy that in general emphasizes primary and secondary prevention. That is the strategic emphasis in the Report of the National Heart, Lung, and Blood Institute (NHLBI) Task Force on Research on CV Epidemiology and Prevention [2]. This concept, that in order to end the epidemic it is necessary to move to a higher plane than before, has as its foundation the achievement to date; it is not a statement of desperation in the face of defeat. Rather it addresses the next important state of advance, based on the achievement to date—what is necessary to continue, maintain, and extend that achievement. Let me here note in saying
this that, as far as I know, nowhere in the world is there yet at the national level an actual policy commitment to primordial prevention of the risk factors. I dont think that such an explicit policy commitment exists anywhere, not, to the best of my knowledge, in the American Heart Association (AHA), the American College of Cardiology (ACC), the NHLBI, the National Institutes of Health (NIH), or the U.S. Department of Health and Human Services. I am convinced that getting policy commitments at the highest level is an essential step forward for public health. We must fight to register this as public policy, just as in 1970 in the Report of the Inter-Society Commission for Heart Disease Resources (ICHD) we registered population-wide primary prevention as the key strategic emphasis, set down its specific components, and stressed the importance of making available long term the necessary resources to accomplish this task [3]. The second aspect of the contest of our deliberations that I want to highlight is that primordial prevention of the risk factors is for all strata of the population—all socioeconomic, ethnic, and regional strata—beginning with all pregnant women. There is already enough confirmation of what Barker et al. first found to enable us to conclude that major risk factor status is influenced to a degree in utero. Thereafter, primordial prevention must relate to all postweaned infants, weaned, it is hoped, not from the bottle but rather from the breast because that is healthier from many points of view, ranging from type of ingested fat and amount of salt consumed to immunologic mechanisms. It continues with primary and secondary school children and with youths and young adults as they make the transition— decisive in terms of the mass development of high-risk status—from youth into middle age. As we heard here,
S130
0091-7435/99 $30.00 Copyright q 1999 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
PRIMORDIAL PREVENTION OF CVD RISK FACTORS
there are now extensive data on that. Clearly, for several key reasons the notion in certain quarters to forget about younger people, men and women, is wrong. In terms of content, primordial prevention encompasses all aspects of lifestyle. It means helping to achieve cohorts with 40, 60, or 80% of the population at low risk—instead of the less than 10% nowadays—with optimal serum cholesterol and blood pressure levels, not smoking, not obese, not diabetic. We can help to create larger and larger cohorts like this only by addressing all aspects of lifestyle, doing this concurrently and continuously. And I agree very much with what Steve said, diet and exercise are crucial in this regard. It is often said by some public health people that achieving progress in reducing prevalence of smoking in the population is the single most important practical way to advance public health. Not quite entirely valid; they are making a good point, but in a one-sided way in my judgment. It certainly is a very important way, but in my judgment its not the single best way. The roots of this epidemic, as anyone who ever produced atherosclerosis or hypertension in experimental animals knows, are first and foremost nutritional. Hence it seems to me to be a useful function of this closing Summary Panel to emphasize two decisive nutritional specifics given little attention over these 2 days; first, the important role—in producing clinically significant severe atheroslerosis at epidemic levels—of habitual excessive dietary cholesterol intake and second, the important role—in producing population-wide adverse blood pressure levels—of habitual excessive salt intake. To implement primordial prevention, we need sustained, effective, specific societal efforts, including a focus on lower socioeconomic strata, to resolve the social and economic problems that stand in the way of achieving the comprehensive changes in lifestyles required. Here I reemphasize the point that Grethe made, and this is my last specific point, that we need to get across much more about foods. We talk in our meetings mostly about nutrients, but people buy foods. They buy them in fast food establishments, grocery stores, cafeterias, vending machines, supermarkets. For all people, we need to make clear what we are talking about: more whole grains, beans, fruits and vegetables, fat-free dairy products, egg whites without the yolks, fish and shellfish, lean poultry, and lean meat. Those are the emphases. Less processed fast food means fewer processed main dishes, mostly high in calories, salt, and fat; less high-fat meat generally, fewer high-fat commercial baked goods; fewer high-fat dairy products; few or no egg yolks; less of the visible fats, to get total fat down to under 30% or even under 25% of calories. Alessandro Menotti gave us brief insight into progress in Italy along these lines. We also need less loading of foods with salt by commercial food processors. Seventyfive percent of ingested salt comes from commercially
S131
processed foods; salt is a major food additive. We need to convey this comprehensive message about foods to the people, about enjoying and enhancing the pleasure of eating in these modified ways, based on the best aspects of the eating styles of all our ethnic strata. What is needed is a new policy commitment to this higher level effort, a la the ICHD report and AHA and NHLBI reports of 2 decades ago. And what is needed also are the resources to implement this and a hearty rebuff to the notion that economic scarcities make this impossible. I get weary reading in medical journals the litany about scarcities, that the demands of the people for medical care are boundless, our resources are limited, rationing is essential, etc., etc. Two points on this in closing: One—in the middle of the 19th century in this country and Britain, in the face of horrendous health conditions and in societies at a much lower level of economic and technologic development than now, movements powered largely by the laity created modern public health, mobilized resources to overcome the problems and the resistance of special interests, did the job, and changed the whole scene. Two—if resources could be mobilized then, the idea cannot be valid that there is nowadays a true scarcity of resources in our much wealthier and more advanced countries. The nub of the problem is persistently aberrant national priorities, first and foremost hundreds of billions endlessly spent on maintenance of a military–industrial complex and endless postponement of any “peace dividend.’’ A peace dividend is needed for the health of the people. Thank you. REFERENCES 1. Reeder B, Chockalingan A, Dagenais G, MacLean D, Nair C, Petrosovits A, Shuaib A, Skwarchuk D, Taylor G, Wielgosz A, Wilson E, in collaboration with Health Canada, Laboratory Center for Disease Control, Statistics Canada, University of Saskatchewan. Heart disease and stroke in Canada, Ottawa: Heart and Stroke Foundation of Canada, 1997:9. 2. Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases. National Heart, Lung, and Blood Institute Report of the Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases. Bethesda (MD): U.S. Department of Health and Human Services, National Institutes of Health, 1994. 3. Inter-Society Commission for Heart Disease Resources, Atherosclerosis Study Group and Epidemiology Study Group. Primary prevention of the atherosclerotic diseases. Circulation 1970;42:A55–95. Steve Fortmann
Thank you, Jerry. Let me also add my thanks to Russell Luepker for including me in the program and to Henry Blackburn for the leadership he has provided to our enterprise in cardiovascular epidemiology and prevention for all of the years that I have been involved in it. While I never attempted to make the transition
S132
STAMLER ET AL.
from California to Minnesota, the influence was nevertheless strong from the distance. I want to emphasize, first, some things that have been left unstated perhaps because of the audience. I think we have not stated explicitly that primordial prevention is indeed possible. There is no obligatory level of atherosclerosis in a population; adult blood pressure does not normally rise with age and neither does serum cholesterol or weight. Second, the causes of epidemic cardiovascular disease are pretty well understood and there is much to do with the knowledge that we now have. It has been one of our assumptions in this conference that diet and physical activity are two of the most fundamental behaviors for primordial prevention and, while we have much to learn about them, there is also much we can do now. I want to highlight two other themes that came out of the Conference. One is the social and community aspects of primordial prevention: Drs. Tyroler, James, Mittlemark, and Kaplan all touched on this. We cannot view the primordial prevention of cardiovascular disease as an isolated problem, differentiated from other problems in society, differentiated from general educational levels, other disease problems, the cultures that we are working with, the networks within communities, etc. One of the most important risk factors for cardiovascular disease is educational level. This means that anything that is done to improve the general educational level is liable to improve cardiovascular disease rates. I appreciate that there is limited cause and effect proof for that statement, but I think we would accept its truth. Yet, political efforts to improve education in this country almost never mention that health benefits would likely come from such improvements. We also cannot view cardiovascular risk in isolation for the high-risk subgroups in the United States who also face violence, economic underdevelopment, and especially adverse dietary patterns. We have been reminded here of the importance of culture as a concept in approaching these groups and also the importance of making these approaches community-based, coming from the communities. Second, the challenges of primordial prevention are never more salient than when we consider exercise, on which we had little impact in the Five-City Project, certainly much less than we would have hoped. Physical inactivity is woven into the fabric of this country, in transportation, food delivery, food storage, etc., so intimately as to be daunting to the health activist. Even those of us who are the most active achieve that status by grafting some exercise on an otherwise sedentary existence. We cannot easily walk to the grocery store if there are no sidewalks and we have to transport enough food to fill the freezer at home. Neither can the
inner city dweller, if there is no store in the neighborhood. Here primordial prevention requires that we address city planning functions, perhaps we need health impact statements as well as environmental impact statements for urban planning. This is an inopportune time in the United States to suggest another layer of bureaucracy or regulation. Yet again, I think we might find a very receptive audience if we began to point out to the public the health impacts of some of these decisions. We need to understand better the characteristics of the communities in which we have observed improving health status without any help from any of us. Dr. Menotti pointed out how much change in Italy has been achieved with few organized efforts. When the right people know what needs to be done, they do not need academic activists to help them out. I must also mention the role of the media (being from Stanford). The media may have played a role in Italy, as Dr. Menotti reminded us, and Dr. Finnegan showed us very interesting data on the role of the media in this country. It may be that the U.S. media can achieve a lot of health education even at the level that it will sustain on its own (with some coaxing and help from public health advocates and agencies). This may have much to do with the salience of the information provided. In the Five-City Project we ended up estimating (I wont attempt to give you a standard error) that we achieved about 5 hours of education per person per year to the average individual in Monterey and Salinas. That compares to the average Americans exposure to 292 hours per year of television advertising alone. Yet, the message got out, people knew about the project, and knowledge levels, at least, changed. We wont argue here about the behavioral effects, but certainly the message was heard and I think that is partly because the population, in fact, is ready to receive it. I will close by commenting on funding for health promotion efforts and the relationship of prevention with the medical care system. I do not label it a health care system, because it is not such. However, primordial prevention, as any sort of prevention, needs a sustained effort. If you think about it, most of the decline in tobacco smoking in this country has been the result of a 30-year information campaign that did achieve behavior change. We have to take a long view of primordial prevention. I think public health agencies are the appropriate place to address these issues but at present they are overburdened with indigent care, underappreciated, and poorly funded. This time of turmoil in the medical care system is an opportunity, I hope, for closing the unnatural distance between the medical care and public health systems in the United States. We need closer cooperation to make progress. Dr. Terris comments about taxing medical care expenditures to provide sustainable funding are most salient. It would take a very small tax on the enormous monies expended
S133
PRIMORDIAL PREVENTION OF CVD RISK FACTORS
for medical care to provide ample funding for both public health and biomedical research. This brings us to the undeniable fact that we must become better at political advocacy to address primordial prevention;. The tobacco control effort in this country is a good example of how public health efforts can be augmented significantly by advocacy. Thank you again, Jerry and colleagues. Grethe Tell
Thank you, Jerry. I would like to thank Russell Luepker for inviting me to be on this panel. Its an honor to have been invited and also somewhat humbling trying to add to this stimulating conference honoring one of my great mentors. I began my epidemiologic training at the division of Epidemiology when I came here from Norway in 1981. I spent 5 years in the division under Henry’s leadership and Russell’s tutorship, 5 years that have meant a lot to me. Thank you. I would like to start by commenting on what was mentioned about social inequalities by a few of the speakers during the conference. Social inequalities are often accompanied by health inequalities. Much attention has been devoted to fairness, equality, and access to such rights as voting, economic security, housing, and jobs. We now need to extend this attention, this battle, to include equal opportunity to healthy living. We, as scientists, need to become more politically active and help make healthy living a political issue. Epidemiologists can contribute to the policy-making process by providing both their data and their specific expert insights; we need to get messages across, to those who need them the most, that it is their right to have a healthy life. How do we get these messages across? During this conference we have heard several suggestions about how to proceed, at least on how to start the process. George Kaplan talked about our obligation to influence macroeconomics, especially with regard to implications for tobacco use. Sherman James pointed out the need to be aware of cultural values and beliefs and to be better students of culture. Access to resources, forming community-based partnerships, and involving the media are also important. Cheryl Perry and Maurice Mittelmark emphasized the importance of social influences. We must act on all these levels in interdisciplinary teams. I believe this is one of the most important messages we have heard at this conference—the need to be interdisciplinary in our approach, to make people aware of their right to healthy living, to make public policy be more responsive to the demands of the people themselves, and to instigate diffusion with a political and social focus. Unfortunately, the list of speakers at this otherwise excellent conference does not include any representatives from the newly independent states of the former Soviet Union. We know that cardiovascular diseases
and their risk factors are highly prevalent in that region, and pollution, economic conditions, and stress all increase the urgency for more effective preventive measures in the new states of Eastern Europe. I would like to end my comments with a few words about diet. This morning Sherman James proposed that we probably should focus much attention on smoking and physical activity intervention because that’s where we are most likely to achieve better results. Although I to a large extent agree, a focus on diet for the primordial prevention of cardiovascular diseases continues to be warranted. Clearly, there is much yet to learn about the role of diet in primordial prevention. Cheryl Perry pointed out the high fat intake among adolescents in Minnesota. I lived in North Carolina for 8 years and I’m familiar with the traditional North Carolina diet, extremely high in fat and a large contributor to the high prevalence of obesity, especially among women. Similarly, the contemporary diet in Eastern Europe is often unhealthy with too much fat and too few fruits and vegetables. We dont know enough about the determinants of dietary habits. While there is an abundance of descriptive studies reporting that people eat so-and-so many units of various nutrients, little is known about why people eat what they eat. We need to focus our research not only on the nutrients, but also on the foods that people eat and find out why people eat what they eat. There are, in the United States, subgroups of this population that are in complex ways at risk for nutrition-related diseases—not only those caused by too much fat or energy, but also diseases caused by too little of certain nutrients. It is time to move beyond the fat and cholesterol issue and expand our horizon about causes of cardiovascular diseases. The recent focus on homocysteine as a “new’’ risk factor is illustrative, and recently intake of folic acid has been related to homocysteine, as well as to cardiovascular and other chronic diseases. We need to focus on other vitamins, antioxidants, and minerals and trace elements. I think we need more research on why young women eat what they eat, or why they dont eat. Considering the relatively high prevalence of eating disorders among adolescent girls, we need to be careful when advising this group to reduce their fat intake. Finally, we need more research on how to avoid weight gain after smoking cessation, the reason many women refuse to quit smoking. Enhanced attention to these contemporary challenges in public health nutrition can contribute greatly to primordial prevention. Thank you. Bob Levy
Thank you. I feel a little bit like the prodigal son who has been away for at least a short period of time. Others have talked about their personal involvement. Let me just say that Jerry Stamler and Henry Blackburn began
S134
STAMLER ET AL.
to teach me epidemiology when I was appointed as a lipid expert to the Data and Safety Monitoring Committee of the Coronary Drug Project some 30 years ago and they have been teaching me ever since. I also was fortunate enough to have been a participant at the WHO meeting that authored the first document on the primary prevention of coronary disease. Both Dr. Stamler and Dr. Blackburn played a major role at that meeting. As I look and listen and react over the past day and a half, I am impressed with the fact that the cup is half empty and half full. Nothing has changed, and much has changed. We see that the same risk factors, even the so-called new ones, are really not new, they have just been rediscovered. We see the same issues, primary versus secondary, the public health approach versus the high risk approach. We see the concepts that were talked about at the WHO meeting on primary prevention continuing to boil and come forward. It was said at that time that the representatives from developing countries in Africa and Asia wanted everything we had, including heart disease and stroke. As I sit here today, I realize that they are on the way to obtaining these things unless some things change. We see the same villains, the tobacco lobby, indifference, focus in the medical area on acute care, poverty, lack of education, lack of incentives, and the media that can be very helpful but can also be villains. I am also impressed, however, that much has changed. We have better genetic and environmental epidemiologic tools, certainly the power of the computer sciences gives us the ability, not only to analyze data, but to transmit it worldwide in an instant. The database is even greater and immensely more persuasive than it was just 10 or 15 years ago, both on the identity of the risk factors and the effect of risk factor change on the disease we are talking about, coronary heart disease. There is a massive credible body of evidence now that has been replicated, as well as a large number of reports on how to accomplish risk factor change. We have greater experience and more knowledgeable practitioners in demonstration and education, a new cadre of people who are articulate workers in the field of coronary disease prevention. I am impressed with the remarkable consensus that has been presented here over these 2 days on what the problems are and what needs to be done. I am also impressed, in part, from my vantage point now in industry, that health care is itself in transition. Folks talk about managed care as if it was one thing, but its many things all struggling for center stage. Certainly cost containment is one element here and I can’t help but think about the number of times I ended my presentations in the past with the fact that prevention of disease was the most cost-effective means we have available.
We have questions right now about the future of the individual health care provider, the academic health center, even the role of the government in health. To me the time seems right, and perhaps it has already begun in Victoria [1] or Catalonia [2], to discover, or rediscover, the power and potential of an efficient coordinating structure on an effort, this time focused on all of prevention, primordial through secondary. A major focus would be to sustain the proactivity that I have heard and seen, with the AHA–ACC combined meeting published just recently with others in prevention, to capture the minds, the attention, the interest of new players, new players in government and new players in managed care. As I sat and listened over these 2 days, I thought about the fact that the time was right to go forth, much as the National High Blood Pressure Education program did over 20 years ago. What did that require? It required political activism by people like Mary Lasker who wouldnt take “no’’ for an answer. It required receptors in government, and there is no better time to find receptors in government than during an election year. It required willingness of parties to get together, to coordinate, to share, to leverage resources. When you look at how much each participating group spent in the National High Blood Pressure Program, it was pennies. When you look at the effect of the program with all the groups together, it had a major, invaluable impact. The National High Blood Pressure Education Program, when it started, had three parts for its base. One was research, and it is quite clear there is still much that we need to know. Another part was education, both public and private. A third part was demonstration. All this clearly needs to be part of any current effort, an effort that certainly should be national and then, clearly, global. The National High Blood Pressure Education Program worked because it included all of the major players, the voluntary health societies, the health care providers and users, government and industry, and minority and majority representatives, and it used all routes and avenues, including the legislative arena and the media. All this could be done now. The time is right. What one needs is some leadership to rekindle the effort and, I must say, if I was disheartened at all during these 2 days, it was when I realized that in some of our accomplishments, reinoculation or inoculation is vitally important and we are beginning to see a recidivism that needs to be prevented. I think that if and when we can get people together to go forth in a coordinated approach, it would be a fitting tribute to the careers of the gentleman sitting to the right of me, Dr. Stamler, and Henry Blackburn as well. If one does not go forward at this time, perhaps because of a shortage of leadership, I still think that
PRIMORDIAL PREVENTION OF CVD RISK FACTORS
one has put together an incredible legacy of solid evidence and I’m truly impressed with the ardor, capability, and capacity of the students and disciples of Henry Blackburn, and suggest that if we dont go forth now, we will go forth in the future, but the time is right now. REFERENCES 1. Advisory Board, First International Heart Health Conference, The Victorial Declaration. Victoria, British Columbia. 2. Advisory Board, Second International Heart Health Conference, Barcelona, May 28–June 1, 1995. The Catalonia Declaration: Investing in Heart Health. Barcelona: Generalital de Catalunya, Autonomous Government of Caldonia, 1995. Ron Prineas
Jerry, thanks very much. As we have gone through this we have heard repetition of themes from all of the presentations in the past day and a half and we need to summarize the major points. We have been presented with lists of barriers to primordial prevention and presenters have attempted to delineate what needs to be done to lead us to primordial prevention. How we finally achieve primordial prevention still remains problematic. Again and again, poor education and low income have been reiterated as major barriers. To make changes there we need social engineering on a scale that we probably dont know how to do very well in this country. One of the things that has remained with us, if you look back through the history of this country or any Western country, is that we have always had poverty and we’ve always had lack of education. It is time that poverty and lack of education are engaged by the prevention community. It becomes more hopeful if we look globally and try to think about solutions for countries like India (heard about at this conference), which is trying to avoid the importation of bad habits from more developed countries. The shared label policy has been particularly emphasized from the presentations this morning, and it is clearly a very important goal.
S135
If, like Grethe, I can single out a major risk factor that has been neglected, it is obesity, particularly in this country and other Western countries, despite decreases in smoking, blood pressure levels, serum cholesterol levels, and dietary intake of fat. Obesity continues to increase in prevalence and the intervention/prevention for that includes not only diet, but also exercise. As I’m talking about diet, we probably need to rethink the macronutrient levels that we aim for and I suggest that the goals for Healthy People 2000 be looked at again and that new targets be set. We really are very bold talking about primordial prevention when we are still doing a less than optimal job with primary prevention and secondary prevention. But having said that, we started primary prevention before we carried out secondary prevention very well, despite which we have had some very large successes, so it shouldn’t prevent us from initiating efforts for primordial prevention now. There is a continuum that has been mentioned many times in the past day and a half: in order to have primordial prevention, we require the optimum social structure in which the good habits of children are nurtured and affect their behaviors as they grow old. This cannot be readily achieved in the presence of high-risk factors and disease among their parents and in the rest of the community. So we really do need to have primordial prevention, primary prevention, and secondary prevention, all going on togther. Other preventive strategies need also be considered. Whenever we have been able to achieve ‘‘passive’’ prevention in public health, such as good sanitation or fluoridation of the water supply, we have been successful in disease. Correspondingly, fortification of foods could become an important primordial preventive measure. Folic acid and antioxidants are possibilities for consideration. I don’t think very much has been said about that in the past day and a half. Clearly the challenges of primordial prevention are multiple and complex—but the rewards from progress in meeting them are likely to be vast.