1. Cardiovascular Disease and Related Risk Factors in Virginia Stephanie M. Gruss, PhD, MSW Epidemiologist Virginia Department of Health (VDH) Division of Chronic Disease Prevention & Control

2. Overall Impact of Chronic Disease in the U.S. By 2030, there will be about 71 million adult baby boomers who will have reached their 65 th birthday. At least 80% of older adults (age 65+) have at least one chronic disease; 50% have two. Chronic diseases claim the lives of 1.7 million Americans each year—70% of all deaths. Heart disease, stroke, cancer, COPD, and diabetes account for two-thirds of all deaths. Sources: “The State of Aging and Health in American”, CDC and Merck Institute on Aging and Health, 2004, 2007; “The Burden of Chronic Diseases and Their Risk Factors”, CDC, 2004; Boult et al. American Journal of Public Health 1996; 86(10), 1388-1393.

3. Cardiovascular Disease (CVD) Mortality

4. Impact of CVD in the U.S. Cardiovascular disease (CVD), including heart disease and stroke, is the #1 killer of Americans, accounting for more deaths in the U.S. than all cancer, accidents, and other chronic disease deaths combined. Almost 700,000 people die of heart disease in the U.S. each year, accounting for about 29% of all U.S. deaths. Blacks had the highest heart disease mortality rate at 300/100,000, followed by whites at 228; 51% of heart disease deaths were to women. In 2006, heart disease is projected to cost more than $258 billion, including health care services, medications, and lost productivity. Source: CDC, Heart Disease Fact Sheet-http://www.cdc.gov/dhdsp/library/fs_heart_disease.htm; http://www.cdc.gov/heartdisease/.

5. CVD Deaths in VA, 2005 A total of 19,081 Virginians died from major CVD in 2005. CVD accounts for 33% of all deaths. Of those deaths, 14,132 people died from heart disease and 3,666 died from stroke. Total CVD mortality rate was 267.2/100,000 population; 197.2 for heart disease and 52.0 for stroke. Source: VDH, Division of Health Statistics, 2005; rates are age-adjusted per 100,000 population.

6. Leading Causes of Death in VA, 2005 Source: VDH, Division of Health Statistics, 2005; *Unintentional Injury.

7. CVD Deaths in VA, 2005 TotalTotal CVD mortality rates, including heart disease and stroke, have significantly declined in Virginia since 1995; primarily for whites and Blacks. ‘Other’ races and Hispanics have shown little to no decline since 1995. In fact, Hispanic stroke rates have increased. Despite the declining rates, Blacks (particularly males) continue to have the highest mortality rates for CVD, including heart disease and stroke, than any other race/ethnicity in Virginia.

8. CVD Death Rates by Race/Ethnicity in VA, 1995-2005 Source: VDH Division of Health Statistics, 1995-2005; age-adjusted.

9. Heart Disease Mortality in VA, 2005 Heart disease, specifically, was the leading cause of death in Virginia in 2005, as it was in the U.S. In Virginia, heart disease accounts for 25% of total deaths and 74% of CVD deaths. Black males have the highest rates of heart disease mortality in Virginia, followed by white males, then Black females. ‘Other’ females and Hispanic females tend to have the lowest heart disease mortality rates in Virginia.

10. Heart Disease Death Rates by Race/Ethnicity in VA, 1995-2005 Source: VDH Division of Health Statistics, 2002-2005; age-adjusted; Hispanic data unavailable for 2005.

11. Heart Disease Death Rates by Gender and Race in VA, 1995-2005 Source: VDH Division of Health Statistics, 2002-2005; age-adjusted; Hispanic data unavailable for 2005.

12. Heart Disease Death Rates by VA Health District, 2005 The top three health districts with the highest age-adjusted rates of heart disease deaths were: 1. Lenowisco (284.5/100,000) 2. Pittsylvania-Danville (284.2/100,000) 3.Cumberland Plateau (277.9/100,000) Source: VDH Division of Health Statistics, 2002-2005; age-adjusted.

13. Data note: State rates listed here are based on calculations ran by health district, if a data point does not have a corresponding health district location reported, the data point is not included; thus, these rates can vary slightly from overall, state rates.

14. Stroke Mortality in VA, 2005 Stroke, or cerebrovascular disease, was the third leading cause of death in Virginia in 2005. In the U.S., stroke was the second leading cause of death for women and the third leading cause of death for men, behind cancer. All blacks (male and female) have significantly higher stroke rates than any other race or ethnicity. The total Hispanic rate for stroke deaths has doubled from 1995-2005; the Hispanic stroke mortality rate exceeded that for whites for the first time in Virginia history in 2005.

15. Stroke Death Rates by Race/Ethnicity in VA, 1995-2005 Source: VDH Division of Health Statistics, 1995-2005; age-adjusted.

16. Stroke Death Rates by VA Health District, 2005 The top three health districts with the highest age-adjusted rates of stroke deaths were: 1. Southside (76.5/100,000) 2. Chickahominy (71.6/100,000) 3. Norfolk (71.0/100,000) Source: VDH Division of Health Statistics, 2002-2005; age-adjusted.

17. Data note: State rates listed here are based on calculations ran by health district, if a data point does not have a corresponding health district location reported, the data point is not included; thus, these rates can vary slightly from overall, state rates.

18. CVD Deaths and Women Mortality rates for CVD are slowly declining, but at a slower rate for women than men. Although stroke mortality rates are similar for men and women, women are more likely to have a stroke at a younger age (40s or 50s) and are more likely to die from stroke. Nationally, women account for more than 60% of the annual deaths due to stroke, making it the second leading cause of death among American women, preceded by heart disease. Sources: VDH Division of Health Statistics, 2004; http://www.cdc.gov/mmwr/.

19. Hospitalizations Due to CVD

20. Hospitalization Cost of CVD in VA, 2005 The total cost of hospitalizations due to a primary diagnosis of CVD was $3.6 billion. There were 115,988 hospital discharges due to CVD, averaging about $31,038 per admission, up from $22,663 in 2004. Average length of stay was 5.1 days. If hospitalizations for CVD in VA were reduced by just 5% per year, the savings by 2010 would be approximately $900 million. Source: VHI Dataset, 2005; primary diagnoses of all CVD codes.

21. Heart Disease Hospital Discharge Rates by VA Health District, 2005 There were 65,544 discharges due to a primary diagnosis of heart disease; state rate of 88.2/10,000. The top three health districts with the highest age- adjusted rates of heart disease discharges were: 1. Crater (152.2/10,000) 2. Southside (135.6/10,000) 3. Norfolk (132.5/10,000) Source: VHI Health Information, Inc.; rates are age-adjusted.

22. Data note: State rates listed here are based on calculations ran by health district, if a data point does not have a corresponding health district location reported, the data point is not included; thus, these rates can vary slightly from overall, state rates.

23. Stroke Hospital Discharge Rates by VA Health District, 2005 There were 20,181 discharges due to a primary diagnosis of stroke; state rate of 27.6/10,000. The top three health districts with the highest age- adjusted rates of stroke discharges were: 1. Crater (46.5/10,000) 2. Portsmouth (42.7/10,000) 3. Roanoke City (41.4/10,000) Source: VHI Health Information, Inc.; rates are age-adjusted.

24. Data note: State rates listed here are based on calculations ran by health district, if a data point does not have a corresponding health district location reported, the data point is not included; thus, these rates can vary slightly from overall, state rates.

25. CVD and Related Risk Factors

26. CVD and Non-preventable Risk Factors Age- 65 and older Minorities- Blacks, Native Americans Gender- Men in terms of most risk factors; women in terms of stroke and arthritis Persons with a family history of chronic disease (genetics) Young children/adolescents- less physically active today and have higher rates of poor dietary intake; non-preventable because children do not often have control over their own physical activity or dietary intake- parents/other adults do!

27. CVD and Preventable Risk Factors Smoking/tobacco use Obesity- Body Mass Index (BMI) of 30 or greater Overweight- BMI of 25 – 29.9 Poor diet- eating less than five fruits for vegetables per day Sedentary lifestyle- no leisure time physical activity within 30 days High blood pressure and high cholesterol- independent risk factors/conditions associated with type-2 diabetes and heart disease And…lack of education on signs and symptoms of heart attack and stroke!!

28. Recognition of Heart Attack Signs & Symptoms Source: BRFSS, 2001-2005; adults 18+; weighted percents; *Trick question- not meant for respondents to say “yes” to; not a sign or symptom of a heart attack. *

29. Recognition of Stroke Signs & Symptoms Source: BRFSS, 2001-2005; adults 18+; weighted percents; *Trick question- not meant for respondents to say “yes” to; not a sign or symptom of a stroke. *

30. Previous Heart Attack & Stroke as Risk Factors for Cardiovascular Disease 2 to 4 Times the Risk of Early Mortality- Prior to Average Life Expectancy (77.8 yrs. in VA in 2004*) Source: VDH, Division of Health Statistics; *most recent year available.

31. Previous Heart Attack, VA Heart attack prevalence in 2001-2004 timeframe was 3.6%. American Indian/Alaskan Natives (AI/AN) were 1.5 times more likely to have a heart attack than any other race and ethnicity. Whites had the second highest heart attack rates. Source: BRFSS, 2001-2004; adults 18+; weighted percents; based on aggregated rates due to low sample size.

32. Previous Heart Attack, VA, 2001- 2004 * Source: BRFSS, 2001-2004; adults 18+; weighted percents; *data are aggregated due to small sample size.

33. Previous Stroke, VA Stroke prevalence in 2001-2004 timeframe in Virginia was 2.10%. American Indian/Alaskan Natives (AI/AN) were 2.2 times more likely to have a stroke than any other race and ethnicity. Blacks had the second highest stroke rates. Source: BRFSS, 2001-2005; adults 18+; weighted percents; based on aggregated rates due to low sample size.

34. Previous Stroke, VA, 2001-2004 * Source: BRFSS, 2001-2004; *data are aggregated due to small sample size; adults 18+; weighted percents.

35. Tobacco Use

36. Impact of Smoking in U.S. & VA, 2005 Smoking causes coronary heart disease; cigarette smokers are 2–4 times more likely to develop coronary heart disease than nonsmokers. 8.6 million people in the U.S. have a disease caused by smoking; they will likely die from CVD, cancer, or a respiratory syndrome, as a result. Smoking is the leading cause of preventable death. 400,000 deaths annually from smoking, plus 38,000 deaths from Second Hand Smoke (SHS) and 1,000 from prenatal exposure. –9,300 deaths from smoking, plus 950 to 1,690 deaths from SHS and prenatal smoking, in Virginia Source: CDC- http://www.cdc.gov/tobacco/health_effects/heart.htm.

37. Adult Tobacco Use in VA, 2005 20.6% of adults currently smoke cigarettes in Virginia. Over half (53%) of adults who smoked said that they started smoking regularly between the ages of 13 and 17. Smoking rates begin to decline starting at age 50; 40-49 year-olds have the highest rates. Source: BRFSS, 2005; adults 18+; weighted percents.

38. Obesity & Overweight

39. Obesity & Overweight in U.S., 2005 Associated with increased risk for hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, osteoarthritis, and certain cancers The second leading cause of preventable death A combined 61% of U.S. adults were either overweight, obese, or extremely obese (3.0% with a BMI of > 40!) U.S. obesity and overweight rates were highest for men, Blacks, & 50-59 year-olds Source: MMWR, State-specific prevalence of obesity among adults, September 15, 2006 / 55(36);985-988.

40. Obesity & Overweight in VA, 2005 A combined 60.6% of adults were either obese (25.1%) or overweight (35.5%). Prevalence rates tend to be higher in males, Blacks, and 55-64 year olds. Source: MMWR website, CDC, http://www.cdc.gov/mmwr/; VA BRFSS, 2005; adults 18+; weighted percents.

41. Diet

42. Proper Nutrition Diets rich in foods containing fiber (fruits, vegetables, whole grains) may reduce the risk of coronary heart disease, stroke, type 2 diabetes, and certain cancers (oral cavity and pharynx, larynx, lung, esophagus, stomach, and colorectal). Diets rich in milk and milk products can reduce the risk of low bone mass throughout the life cycle. Source: USDA Dietary Guidelines Fact Sheet, 2005.

43. Eating Fruits & Vegetables, U.S. & VA, 2005 In the U.S., the prevalence of eating fruits or vegetables 3-5 times per day was 27.2%. Rates were higher among women, whites, and increased with increasing age. Hispanics had the lowest prevalence rate among any other race or ethnicity. In Virginia, the prevalence of eating fruits or vegetables 3-5 times per day was 37.5%. Rates were higher among women and whites. Rates were lowest for 25-34 year-olds and Hispanics. Source: MMWR, Fruit and Vegetable Consumption Among Adults- U.S., March 16, 2007/ 56(10);213-217; VA BRFSS, 2005; adults 18+; weighted percents.

44. Physical Activity (or, Not!)

45. Sedentary Lifestyle in U.S. & VA, Adults, 2005 Sedentary lifestyle is defined by the CDC as, “not participating in any leisure time activity in 30 days.” About 24% of U.S. adults reported being sedentary! 22.6% of adults in Virginia reported being sedentary. Black females and other non-Hispanic males had the highest rates of sedentary lifestyle. Sedentary lifestyle is associated with hyperlipidemia, hypertension, and obesity. Source: MMWR website, CDC, http://www.cdc.gov/mmwr/; VA BRFSS, 2005; adults 18+; weighted percents.

46. Physical Activity in Children & Adolescents, VA, 2003 64% of high school students participated in vigorous physical activity most week days (at least 5) 27% of high school students participated in moderate physical activity most week days High school students attending physical education classes daily decreased from 42% in 1991, to 25% in 1995, and to 33% in 2005. Source: VDH, WIC Program, “An Examination of Healthy Behaviors in Virginia’s Children,” 2003.

47. Hypertension (High Blood Pressure)

48. High Blood Pressure in the U.S. & VA, 2005 Pre-hypertension defined as blood pressure > 120-139 (systolic) or > 80-89 (diastolic); hypertension defined as anything higher than 140 & 90 and probably requires medication In the U.S., about 1/3 of all adults has high blood pressure- 65 million! Highest prevalence in Blacks. Costly- cause of more doctor’s visits than any other condition; $64 billion/yr. in medical costs 26.7% of all Virginia adults has high blood pressure and rates are similar to U.S.- highest prevalence in Blacks, no significant gender differences, and rates increase with increasing age. Sources: U.S. Department of Health and Human Services, Controlling High Blood Pressure, Legislator Policy Brief, 2007; BRFSS, 2005.

49. Hypertension-Related Deaths in VA, 2005 Hypertension is considered both a risk factor and a form of heart disease. Also an underlying cause of death- “the silent killer” In 2005, hypertensive heart, hypertensive renal disease, and essential hypertension killed 1,050 Virginians. Source: VDH Division of Health Statistics, 2005.

50. High Blood Pressure Trends in VA by Race/Ethnicity, 2001-2004* Source: *American Indian/Alaskan Native; BRFSS, 2001-2004; *data aggregated due to small sample size. *

51. High Blood Pressure Prevalence Rates by VA Health District, 2005 The top three health districts with the highest prevalence rates of high blood pressure were: 1. Pittsylvania-Danville (42.0%) 2. Lenowisco (39.6%) 3. Eastern Shore (38.5%) Source: BRFSS, 2005; adults 18+; weighted percents.

52. Data note: State rates listed here are based on calculations ran by health district, if a data point does not have a corresponding health district location reported, the data point is not included; thus, these rates can vary slightly from overall, state rates.

53. High Cholesterol

54. High Cholesterol in the U.S. & VA, 2005 Optimal cholesterol levels are: LDL (“Bad”) 60, Total <200, Triglycerides <150 In the U.S., 35.6% of all adults has high cholesterol. In the U.S., males have slightly higher rates than females, whites have the highest rates across race/ethnicity, and high blood pressure increases with increasing age. 36.2% of all Virginia adults had high cholesterol and rates were similar to U.S. rates across gender, race/ ethnicity, and age. Sources: U.S. Department of Health and Human Services, National Institutes of Health- National Heart, Lung, and Blood Institute, “High Blood Cholesterol- What You Need to Know,” 2002; BRFSS, 2005.

55. High Cholesterol Trends in VA by Race/Ethnicity, 2001-2004* Source: BRFSS, 2001-2004; adults 18+; weighted percents; *data aggregated due to small sample size.

56. High Cholesterol Prevalence Rates by VA Health District, 2005 The top three health districts with the highest prevalence rates of high cholesterol were: 1. Alleghany (45.1%) 2. Lord Fairfax (43.4%) 3. Chesterfield (43.2%) & Pittsylvania- Danville (43.1%) Source: BRFSS, 2005; adults 18+; weighted percents.

57. Data note: State rates listed here are based on calculations ran by health district, if a data point does not have a corresponding health district location reported, the data point is not included; thus, these rates can vary slightly from overall, state rates.

58. Diabetes Mellitus (DM) Image retrieved from- http://www.fotosearch.com/photos-images/diabetes.html.

59. Diabetes as an Independent Risk Factor for CVD Diabetes can lead to: coronary heart disease, stroke, peripheral artery disease, cardiomyopathy, and congestive heart failure. People with diabetes are two to four times more likely to have a heart attack or stroke than people without diabetes. People with diabetes are more likely to die from a second heart attack than people with CVD who do not suffer from diabetes. A secondary diagnosis of CVD is found in about 75% of all diabetes-coded deaths. Source: http://www.ndep.nih.gov/control/CVD.htm.

60. Diabetes as an Independent Risk Factor for CVD,VA, 2005 Persons with diabetes were 2.4 times more likely to be obese than persons without diabetes Persons with diabetes were 2.9 times more likely to have high blood pressure than persons without diabetes Persons with diabetes were 2.0 times more likely to have high cholesterol than persons without diabetes When looking at the above risk factors in combination with one another, obesity has the highest contribution to a diagnosis diabetes. Source: Gruss, S.M. & Jennings, G.C., BRFSS data analysis of risk factors for having diabetes, 2005.

61. Diabetes Prevalence Rates by VA Health District, 2005 The top three health districts with the highest prevalence rates of diabetes were: 1. Eastern Shore (15.4%) 2. Lenowisco (14.2%) 3. Crater (12.6%) Source: BRFSS, 2005; adults 18+; weighted percents.

62. Data note: State rates listed here are based on calculations ran by health district, if a data point does not have a corresponding health district location reported, the data point is not included; thus, these rates can vary slightly from overall, state rates.

63. Questions?? For more information please see our web page at: http://www.vahealth.org/cdpc/cvh/