Smoking, Salt and the Downside of Success
In the past 55 years, death rates from cardiovascular disease have declined by 68 percent—a two thirds reduction in mortality. Over the same period of time, death from stroke has declined by more than three fourths.
Part 1 of this blog series noted the origins of two entities—the American Heart Institute (AHA) and the Framingham Study—that have been on the forefront of this dramatic decline. Many other institutions and factors had a hand in this achievement, but these two organizations highlight the power of public health research, combined with public education, to save lives. They originated some successes and innovations we now take for granted, and also highlight the remaining challenges.
For instance, when the Framingham Study began, it was so unique it was difficult to explain, and thus generated a new public health vocabulary, including the “longitudinal cohort study,” as it came to be called, and the concept of the risk factor, the basis for primary prevention of chronic disease.
The power of public education was another success: the AHA, as mentioned in part 1, wasted no time in taking the results of the Framingham Study’s (and other) research and educating the public, resulting in profound changes in individual choices and behavior. In 1957, the Centers for Disease Control and Prevention (CDC) and the National Heart, Lung, and Blood Institute (NHLBI), home of the Framingham Study, formed a collaboration to standardize cholesterol measurements. The resulting Lipid Standardization Program has served as the benchmark for medical practice for about 35 years.
Success also showed up in the form of imitation. By the 1960s, the Framingham model had been adopted by other large-scale studies, including the collection of biospecimens. [Despite its successes, the Director of the NIH tried to discontinue the Framingham Study in 1965.]
The AHA has also continued to innovate, including training people in CPR, publishing heart-healthy cookbooks, and creating a certification program for labeling heart-healthy foods in grocery stores and restaurants, and adding caloric information to restaurant menus. The AHA is currently the largest funder of CVD-related research outside the Federal government and the organization has also “gone global,” providing technical expertise on patient care and public health around the world.
Likewise, following Framingham’s footsteps, the many biospecimen collections around the world related to cardiovascular disease are enabling biomarker studies and analysis of the contributions of genetics, stress-induced ischemia, and socioeconomic disparities to cardiovascular disease. Another exciting avenue research is in sports medicine, studying the protective benefits of rigorous exercise.
This should be where we read about the happy ending. Unfortunately, that is not the case. CVD is still the number one cause of death in the US and worldwide, and is responsible for 31 percent of global mortality. According to the World Health Organization (WHO), an estimated 17.5 million people died from CVD in 2012, about 7.4 million from coronary disease and 6.7 million from stroke. The burden is greater in middle- and low-income countries, which account for three fourths of CVD deaths worldwide.
The culprits are familiar: smoking and other forms of tobacco use combined with uncontrolled high blood pressure, which result in continued high mortality as well as disability from CVD, particularly in low-income areas. In wealthier regions, obesity is a major factor as well. The AHA and WHO have both launched global campaigns against CVD, focusing on reducing tobacco use and implementing evidence-based practices to limit salt consumption and optimize blood pressure management and CVD at the point of primary care.
Our success against CVD has a downside, in that CVD overall receives substantially less public health attention—by the general population as well as by funding bodies—than cancer. There is now a perception that a) cardiovascular disease has receded into the background—not true, and b) is self-inflicted—partly true. The risk factors for CVD (smoking, obesity, uncontrolled high blood pressure) account for about 50 percent of cases. Further, when surveyed about what disease they fear most, people overwhelmingly cite cancer, even though CVD is the leading cause of death as well as disability and hospitalizations. These perceptions are reflected in funding levels for CVD.
For instance, from 2012 through 2015, the National Institutes of Health devoted about $21.7 billion to cancer compared to about $9.9 billion to CVD. Reduced to a particularly cold statistic, in 2014, about $19,342.00 was spent per death from breast cancer compared to about $2,659.00 per CVD death.
Likewise, there are more than 250 non-profit organizations devoted to fighting cancer, which is more than those focused on AIDS, Alzheimer's disease, and stroke combined. Similarly, there are far fewer biobanks supporting biomarker and CVD research. These biobanks are also smaller, with collections numbering in the tens of thousands (compared with many millions in cancer-related biorepositories).
Part 1 of this blog noted the shift from epidemiology and public health as the study of “that which is thrust upon us” to “that which we do to ourselves.” In addressing CVD, the new challenge for or evolution of Public Health research as a whole may be to re-balance these two perspectives.
There is a need for more biobanks supporting biomarker and CVD research. The DO-HEALTH clinical trial has established a biobank for biomarkers, to enhance the potential value of the data collected and ultimately improve senior health. To learn more, download our eBook European DO HEALTH Clinical Trial Aims at Simple, Affordable Interventions to Improve Senior Health.
 Stockmann, C.; Hersh, A. L.; Sherwin, C. M. & Spigarelli, M. G. (2014). Alignment of United States funding for cardiovascular disease research with deaths, years of life lost, and hospitalizations. International Journal of Cardiology, 172, 19–21; DOI: 10.1016/j.ijcard.2013.12.095.