Winter 99

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Page 1

W = i n t e r=20 1 9 9 9

N A T = I O N A L=20 I N S T I T U T E S O F H E A L T H

N A T = I O N A L=20 H E A R T , L U N G , A N D B L O O D I N S T I T U T=20 E

Government=20 Releases First

Obesity=20 Clinical Guidelines

In = June, the=20 Federal government released its

first = Clinical=20 Guidelines on the Identification,

Evaluation,=20 and Treatment of Overweight and

Obesity in=20 Adults.

The = release came=20 amid a flurry of media

coverage due to a=20 leak of part of the guide-

lines = before the=20 official release. The double

dose of = coverage=20 brought the guidelines=E2=80=99 mes-

sage of = the=20 dangers of overweight and obesity

to = virtually=20 every American.

After = smoking,=20 obesity and overweight

comprise the=20 second most preventable cause

of = death in the=20 United States. Dr. Claude

Lenfant, director=20 of the National Heart, Lung,

and = Blood=20 Institute (NHLBI), called the con-

ditions = =E2=80=9Ca=20 serious public health challenge.=E2=80=9D

About = 97 million=20 Americans=E2=80=9455 percent

of the=20 population=E2=80=94are now overweight or

obese, = and the=20 number is increasing. The

total = cost=20 attributable to obesity-

related = disease=20 in the United

States = approaches=20 $100 billion

annually.

The = guidelines=20 were

issued = by the=20 NHLBI, in

cooperation with=20 the

National=20 Institute of

Diabetes and=20 Digestive

and = Kidney=20 Diseases

(NIDDK), both=20 part of the

National=20 Institutes of Health.

Developed by a=20 24-member

expert = panel=20 using an evidence-

based = approach,=20 the guidelines

are = meant to help=20 physicians in their care of

overweight and=20 obese patients.

=E2=80=9CThe guidelines=20 are based on the most

extensive review=20 to date of the scientific evi-

dence = on=20 overweight and obesity,=E2=80=9D said Dr. F.

Xavier = Pi-Sunyer,=20 who chaired the expert

panel. = He is=20 director of the Obesity Research

Center = at St.=20 Luke=E2=80=99s/Roosevelt Hospital Cen-

ter in = New York=20 City. =E2=80=9CThe evidence includes

data = from about=20 236 randomized controlled

clinical trials,=20 which form the basis for many

of the=20 recommendations.

=E2=80=9CThe resulting=20 clinical practice guidelines

present = a new=20 approach for physicians to use

in = assessing=20 overweight and obesity,=E2=80=9D he con-

tinued. = =E2=80=9CThey=20 also establish principles of

safe = and=20 effective weight loss.=E2=80=9D

A key=20 recommendation is

that = physicians=20 use three main

measures in=20 evaluating over-

weight = and risk=20 status:

body = mass index=20 (BMI),

the = presence of=20 risk

(continued on=20 page 16)

Featured=20 Articles

1 = GOVERNMENT RELEASES FIRST=20

OBESITY=20 CLINICAL GUIDELINES

3 = SYMPOSIUM EXPLORES THE PROMISE=20

OF=20 INFORMATION TECHNOLOGY IN THE

FIGHT AGAINST=20 HEART ATTACKS

22 = FRAMINGHAM CELEBRATES 50=20 YEARS

AS = THE HEART=20 OF AMERICA

Page = 2

HEARTMEMO

WINTER=20 1999

Letter=20 Fr

om = the=20 Dir

ector Contents

1 = GOVERNMENT RELEASES FIRST=20

OBESITY=20 CLINICAL GUIDELINES

2 = LETTER FROM THE = DIRECTOR

3 = SYMPOSIUM EXPLORES THE=20

PROMISE OF=20 INFORMATION TECH-

NOLOGY IN THE=20 FIGHT AGAINST

HEART=20 ATTACKS

4 = HEARTFILE: NHLBI EDUCATION=20

PROGRAM=20 UPDATES

18 = HEARTNET: INTERNET = SOURCES

19 = HEARTFACTS: HEART = DATA

DITTO:=20 REPRODUCIBLES

21 = HEARTSCIENCE: NHLBI=20 RESEARCH

UPDATES 26

NEW = AT THE=20 NHLBI INFORMATION

CENTER

26 = MARK YOUR CALENDAR

ORDER=20 FORM

E A = R

E A = R=20 T

E M = O

E A = D E R=20 S

Over = the course=20 of this, the 50th year

of the = NHLBI, I=20 have reflected on the

astounding=20 progress we have made in

the = assessment,=20 treatment, and pre-

vention of=20 coronary heart disease

(CHD). = This=20 issue of HeartMemo

looks = back on=20 the milestones of the

past = half=20 century through the prism of

the = Framingham=20 Heart Study (see

page = 22). The=20 findings that have

emerged and=20 continue to emerge from

that=20 revolutionary study have truly

saved = countless=20 lives. When we

think = with=20 nostalgia about the 1940s

and = 1950s, it is=20 sobering to remember

that = those were=20 also days when, due

to = CHD, many=20 more children were

prematurely left=20 fatherless or mother-

less, = and fewer=20 grandparents lived to

see = their=20 grandchildren grow up or

even = be born.=20

Looking ahead,=20 the article on med-

ical = informatics=20 and heart attacks (see

page = 3) gives us=20 a peek into a future

that = will be=20 influenced increasingly

by = technology in=20 ways that the

founders of the=20 Framingham Heart

Study = surely=20 never dreamed. In fact,

most = of the=20 applications discussed in

the = article=E2=80=94such=20 as telemedicine,

large-scale=20 databases, and interactive

Web = sites=E2=80=94are=20 already in existence,

and it = is only a=20 matter of time before

many = become more=20 widespread and

more=20 sophisticated.

Some = of the most=20 significant

strides that=20 have been made related to

health = in the=20 past 50 years have been

cultural. As=20 risk factors for disease

have = been=20 identified, and as it became

clear = that=20 lifestyle modifications can

sometimes=20 prevent disease or change

Letter=20 From the Director

its = course, more=20 health care profes-

sionals have=20 come to view their

patients as=20 partners rather than pas-

sive = observers.=20 Likewise, the public

has = begun to=20 take more responsibility

for = its own=20 health. The new Federal

obesity=20 guidelines and the ongoing

education=20 efforts in cholesterol, high

blood = pressure,=20 sleep disorders, and

minority=20 populations all attest to this

fundamental=20 behavioral shift. The

challenge now is=20 to partner with the

many = more=20 Americans that the

NHLBI=E2=80=99s messages=20 have not yet

reached, and to=20 make every health

care=20 professional a voice for preven-

tion.

Because of the=20 confidence we can

have = in the=20 heart research that has

been = done so far=20 and the exciting pos-

sibilities we=20 know are ahead, I feel

certain that the=20 next 50 years will be

as = inspiring and=20 transformative as the

first. =

Claude = Lenfant,=20 M.D.

Director,=20 NHLBI

=E2=80=94When we=20 think with nostalgia

about the=20 1940s and 1950s, it

is=20 sobering to remember that

those were=20 also days when=E2=80=A6

fewer=20 grandparents lived to see

their=20 grandchildren grow up

or even be=20 born.=E2=80=9C

Page = 3

recognition=20 and

treatment=20 of

individuals

with=20 symp-

toms=20 and

signs = of=20 a

heart

attack.=20 It

led to = a

call=20 for

proposals

on=20 medical

informatics

and, = in=20 Septem-

ber, = the=20 awarding

of = funding to=20 eight

promising=20 applicants.

A = series of=20 tutorials

on the = NHAAP and=20 tech-

nology = provided=20 participants

with a = common=20 starting point.

Dr. = James M.=20 Atkins, medical direc-

tor, = Emergency=20 Medicine Education,

University of=20 Texas Southwestern

Medical Center=20 at Dallas, spoke

about = the=20 achievements of the

NHAAP = since=20 1991, which have

included helping=20 improve the rapid

identification=20 and treatment of heart

attack = patients=20 in the emergency

department. Dr.=20 Atkins also outlined

the = challenges=20 still facing the

NHAAP, = particularly in reducing

patient=20 delay.

Several speakers=20 then focused on

the = promise and=20 limitations of partic-

ular=20 technologies. Although the pace

of = technology in=20 recent years has

transformed many=20 aspects of health

care,=20 frustrating hurdles have arisen.

Problems and=20 potential solutions in

the = areas of=20 Internet congestion, con-

fidentiality of=20 medical records, and

data=20 standardization and access were

Symposium=20 Explores the Promise

of=20 Information Technology in the

Fight=20 Against Heart Attacks

3 HEARTMEMO

WINTER = 1999

Information=20 T

echnology and=20 Heart

Attacks

When = chest pain=20 gripped Dr. Mark

Smith = in the=20 middle of the night earli-

er this = year, he=20 ignored his own best

advice=E2=80=94to call=20 9-1-1. =E2=80=9CWhat did I

do?=E2=80=9D asked Dr.=20 Smith, chairman,

Department of=20 Emergency Medicine,

Washington=20 Hospital Center, Wash-

ington, = DC. =E2=80=9CI=20 stumbled into the

bathroom, took=20 some antacid, and

went = back to bed,=20 hoping that what I

was = having was=20 the heartburn of

esophagitis and=20 not the pain of a heart

attack. = . . . I=20 would have liked to

have = had a home=20 ECG machine that I

could = have=20 strapped onto myself,

taken a = tracing=20 that would have been

compared=20 automatically to my previ-

ous ECG = that was=20 stored, and then be

informed by the=20 machine whether or

not = ST-segment=20 elevation or some

other = change from=20 my previous trac-

ing was = present.=E2=80=9D=20 Sound like some-

thing = out of the=20 X-Files? It may be

closer = to reality=20 than you think.

Dr. = Smith relayed=20 his experience,

which = thankfully=20 proved to be caused

by = esophagitis,=20 or heartburn, at an

exciting=20 symposium he chaired last

April, = called=20 =E2=80=9CNew Information Tech-

nology = and the=20 National Heart Attack

Alert = Program:=20 Setting a Five-Year

Agenda.=E2=80=9D In an=20 unprecedented part-

nership, the=20 NHLBI, the National

Library = of=20 Medicine (NLM), and the

Agency = for Health=20 Care Policy and

Research (AHCPR)=20 cosponsored the

event, = which=20 explored the role of

technology in=20 furthering the mission

of the = National=20 Heart Attack Alert

Program = (NHAAP).

The = meeting=20 sparked plans for

using = medical=20 informatics, or the

medical = application of information

technology, to=20 increase the early

addressed.

Dr. = Craig Feied,=20 direc-

tor of = informatics, Department of

Emergency=20 Medicine, Washington

Hospital Center,=20 Washington, DC,

described the=20 Next Generation Inter-

net, a = multi-agency Federal program

whose = goal is to=20 connect national lab-

oratories and=20 universities with net-

works = that are=20 1,000 times faster than

today=E2=80=99s=20 Internet. Similarly, Internet

2, a = project of=20 the University Corpo-

ration = for=20 Advanced Internet Devel-

opment, unites=20 universities with

public = and=20 private researchers to

develop entirely=20 new Internet prod-

ucts = that will=20 facilitate innovations in

research and=20 education. These

advanced=20 versions of the Internet will

enable = shared=20 access to large health

data = sets and=20 the use of virtual reality

for=20 telemedicine.

Dr. = Paul=20 Clayton, professor and

chair, = Department of Medical Infor-

matics, Columbia=20 University, New

(

continued on=20 page 24

)

Page = 4

HeartFile:=20 NHBPEP

HEARTMEMO

WINTER=20 1999

4 N

E=20 W

L I = N I C A=20 L

R I = A=20 L

E S = U LT=20 S

O N = F I R=20 M

JNC

VI=20 R

E C = O M M E N=20 D AT I O N S

It has = been a=20 year since the National

High = Blood=20 Pressure Education Pro-

gram = (NHBPEP)=20 released The Sixth

Report of the=20 Joint National Commit-

tee = on=20 Prevention, Detection, Evalua-

tion, and=20 Treatment of High Blood

Pressure=20 (JNC VI). The JNC VI

report = provided=20 clin-

icians = with=20 evidence-

based = and=20 consensus

recommendations=20 for

prevention=20 strategies

and = lifestyle=20 and

pharmacologic=20 treat-

ment = of high=20 blood

pressure. Since=20 the

report = was=20 released,

several=20 randomized

controlled=20 trials and

other = studies=20 have

been = published.=20 At

its = meeting in=20 Sep-

tember, the=20 NHBPEP

Coordinating=20 Com-

mittee = reviewed=20 the

results of=20 recent tri-

als = and=20 discussed

how = the findings=20 may impact the JNC

VI=20 recommendations.

Lifestyle=20 Modifications

Increasing=20 scientific evidence from

sources such as=20 the Trials of Hyper-

tension=20 Prevention

confirms that=20 los-

ing = weight is=20 probably the most

important thing=20 a person can do to

prevent or=20 control high blood pres-

sure. = However,=20 new studies also have

provided data on=20 the effects of potas-

sium, = magnesium,=20 and alcohol intake.

Based = on the=20 results of the DASH

(Dietary=20 Approaches to Stop Hyper-

Study=20 participants did not achieve

the = expected=20 alcohol reduction;

therefore, blood=20 pressure lowering

was = less than=20 expected. The authors

noted = that=20 although moderating alco-

hol = intake is=20 important for overall

health, it is=20 only one part of therapy

to = lower blood=20 pressure.

Pharmacologic=20 Therapy

A = recent=20 fol-

lowup = to=20 the

Systolic Hypertension

in the = Elderly

Program (SHEP) 6 examined metabolic

effects,=20 such

as = lipid=20 lev-

els,=20 in

patients=20 given

a=20 diuretic

versus

patients=20 given

a=20 placebo.

This=20 analysis

confirmed

that=20 diuretics

reduced=20 cardiovascular morbidity

and = mortality,=20 which supports the

JNC VI = recommendation to use

diuretics as a=20 first-line treatment for

uncomplicated=20 hypertension.

Several recent=20 trials compared

ACE = inhibitors=20 to other drugs in

patients with=20 and without diabetes.

7-8

All of = the=20 studies provided further

evidence that=20 ACE inhibitors lower

tension)=20 study

and = others,=20 there is

mounting=20 evidence that adequate

potassium intake=20 (about 90 mmol per

day), = as=20 recommended in the JNC VI

report, helps=20 lower blood pressure. A

new = study=20 indicates that taking mag-

nesium = supplements also may lower

blood = pressure=20 slightly.

However,=20 yet

another=20 study,

which = examined=20 the

effects of=20 potassium, calcium, and

magnesium=20 supplements separately

and in = combination, concluded that

only = potassium=20 lowered blood pres-

sure. = Clearly,=20 more research is needed

on the = effect of=20 magnesium and calci-

um on = blood=20 pressure.

The = Prevention=20 and Treatment of

Hypertension=20 Study (PATHS)

5 report-

ed = that=20 consuming large amounts of

alcohol may=20 raise blood pressure.

The=20 National High Blood

Pressure=20 Education Program

=E2=80=A2 Lose weight if=20 overweight.

=E2=80=A2 Limit alcohol=20 intake.

=E2=80=A2 Increase=20 aerobic activity to 30 to 45 minutes most days of the week.

=E2=80=A2 Reduce sodium=20 intake. The goal is not more than 100 mmol per day.

=E2=80=A2 Maintain=20 adequate intake of potassium (about 90 mmol per day).

=E2=80=A2 Maintain=20 adequate intakes of calcium and magnesium for general

health.

=E2=80=A2 Stop smoking=20 for overall cardiovascular health.

=E2=80=A2 Reduce intake=20 of dietary fat and cholesterol.

J N = C V I=20 L

I F = E S T Y L=20 E

E C = O M M E N=20 D A T I O N S

References

1. The = Trials of=20 Hypertension Prevention

Collaborative=20 Research Group. Arch Intern Med

1997;157:657-667.=20

2. = Appel, et al.=20 N Engl J Med 1997;336:1117-1124.

3. = Kawano, et=20 al. Hypertension 1998;32:260-265.

4. = Sacks, et al.=20 Hypertension 1995;26:950-956.

5. = Cushman, et=20 al. Arch Intern Med 1998;158:1197-1207.

6. = Savage, et=20 al. Arch Intern Med 1998;158:741-751.

7. = Tatti, et al.=20 Diabetes Care 1998;21:597-603.

8. = Estacio, et=20 al. N Engl J Med 1998;338:645-652.

9. = Hansson, et=20 al. Lancet 1998;351:1755-1762.

Page = 5

HeartFile:=20 NHBPEP

5 HEARTMEMO

WINTER = 1999

blood = pressure,=20 although usually in

combination with=20 other drugs. ACE

inhibitors also=20 provide some renal

protection in=20 patients with diabetes.

The JNC = VI report=20 states that there

is = compelling=20 evidence to use ACE

inhibitors in=20 type 1 diabetes and that

ACE = inhibitors=20 may have favorable

effects = in type 2=20 diabetes. This new

information=20 provides more evidence

that = ACE=20 inhibitors can be helpful

in type = 2=20 diabetes as well as type 1.

The = Hypertension=20 Optimal Treat-

ment = (HOT)=20 study

attempted=20 to

refine = the=20 maximum benefit to blood

pressure levels=20 as a result of treat-

ment.=20 The

investigators treated

patients=20 until

they = reached=20 a

diastolic

blood=20 pres-

sure = goal=20 of

below=20 90,

below = 85,=20 or

below = 80=20 mm-

Hg. All = three

groups showed

reductions=20 in

mortality=20 and

morbidity.=20 At

these=20 levels,

no=20 J-curve=E2=80=94

that = is,=20 an

increase in=20 morbid events at the

lower = pressure=20 levels=E2=80=94was evident.

HOT = supports the=20 JNC VI report

recommendation of=20 a treatment

blood = pressure=20 goal of below

140/90.

The = evidence that=20 has emerged

over = the past=20 year has upheld or

strengthened the=20 JNC VI recom-

mendations. As=20 additional findings

are = revealed over=20 the next few

years, = the NHBPEP=20 will be watch-

ing = closely to=20 see if they cast a

new = light on the=20 JNC VI recom-

mendations. H

I G = H

L O = O=20 D

R E = S S U R=20 E

D U = C AT I O=20 N

O N = T=20 H

AT = E R I A L=20 S

N L = I N=20 E

May is = National=20 High Blood Pres-

sure = Education=20 Month, and now is

the = time for=20 community organizers

and = health=20 departments to begin

planning for=20 health promotion and

education=20 activities. The theme for

this = year =E2=80=99s=20 activities is =E2=80=9CIf Your

Blood = Pressure=20 Is Not Lower Than

140/90, Ask Your=20 Doctor Why.=E2=80=9D

The = focus will=20 be on the value of

lowering blood=20 pressure in those

with = high blood=20 pressure (above

140 = mmHg=20 systolic or 90 mmHg

diastolic), with=20 increased emphasis

on = preventing it=20 from rising in

those = with=20 high-normal blood pres-

sure = (between=20 130 and 139 systolic

or 85 = and 89=20 diastolic).

As in = the past,=20 a kit will be

available from=20 the NHLBI Infor-

mation = Center.=20 Beginning April 1,

you = will be able=20 to download the

kit = from the=20 NHLBI Web site,

http://www.nhlbi.nih.gov, = making

it = easy to pick=20 and choose the

materials that=20 would work best for

your = program.=20 You can also order

bulk = materials=20 through the site.

Important=20 messages to highlight

during = National=20 High Blood Pres-

sure = Education=20 Month are:

=E2=80=A2 Controlling=20 high blood pressure

to = below 140/90=20 mmHg can dra-

matically reduce=20 your chances

for = having a=20 stroke or heart

attack = and add=20 years to your

life=E2=80=94time you=20 can cherish with

your = spouse,=20 children, grand-

children, and=20 friends.

=E2=80=A2 Only one out=20 of four people

with = high blood=20 pressure is con-

trolling it. We=20 can do better!

=E2=80=A2 Preventing=20 high blood pressure

is = possible=20 by

maintaining=20 an

ideal=20 weight,

increasing=20 exer-

cise, = reducing=20 salt

in the = diet,=20 moder-

ating = alcohol=20 use,

and=20 increasing

potassium in=20 the

diet. = These=20 strate-

gies = can also=20 help

control high=20 blood

pressure in=20 many

individuals.

=E2=80=A2 Encouraging=20

family = members=20

or = friends with=20

high = blood=20 pres-

sure = to stay on=20

therapy is one=20 of

the = best ways to=20 help them control it.

Screening=20 activities, walk-a-

thons, = health=20 fairs, and media

events = have been=20 scheduled during

May to = celebrate=20 the progress

made = in reducing=20 the rates of

death = from heart=20 disease and

stroke. National=20 High Blood Pres-

sure = Education=20 Month is an ideal

time = for health=20 professionals to

focus = on ways to=20 continue this

progress.=20

For = more=20 information, contact

the = NHLBI=20 Information Center.

(continued on=20 page 6)

=E2=80=A2 Start with a=20 diuretic or beta- blocker unless compelling indications

exist.

=E2=80=A2 Compelling=20 indications for coexisting conditions:

=E2=80=A2 Diabetes=20 mellitus (type 1 with proteinuria): angiotensin converting

enzyme = (ACE)=20 inhibitor.

=E2=80=A2 Heart failure:=20 ACE inhibitor or diuretic.

=E2=80=A2 Isolated=20 systolic hypertension: diuretic (preferred) or calcium

antagonist.

=E2=80=A2 Myocardial=20 infarction: non- ISA beta-blocker; ACE inhibitor with=20 LVH.

J N = C V I=20 P

H A = R M A C O=20 L O G I C

E C = O M M E N=20 D A T I O N S

Page = 6

HEARTMEMO

WINTER=20 1999

HeartFile:=20 NHBPEP

I E = T

A=20 N

E L = P

O W = E=20 R

L O = O=20 D

R E = S S U R=20 E

How = much can=20 changing your diet

really = improve=20 your blood pres-

sure? = Most of=20 the research, until

now, = has focused=20 on the effects of

only = one=20 nutrient on blood pres-

sure, = rather=20 than combinations of

nutrients.=20 However, a recently

released study,=20 the Dietary

Approaches to=20 Stop Hypertension

(DASH) = trial,=20 investigated how an

entire = diet=20 plan=E2=80=94and the combina-

tion = of=20 nutrients=E2=80=94influences blood

pressure. From=20 this study, the

investigators=20 developed an eating

plan = designed to=20 lower elevated

blood=20 pressure.

The = study=20 compared three differ-

ent = eating=20 patterns: a plan similar

to = what many=20 Americans consume;

a plan = similar=20 to what many Ameri-

cans = consume but=20 higher in fruits

and = vegetables;=20 and a combination

plan=E2=80=94the DASH=20 diet=E2=80=94lower in

saturated fat,=20 total fat, and choles-

terol = and rich=20 in fruits, vegetables,

and = low-fat=20 dairy foods. All of the

foods = included=20 in the study were

commonly=20 available.

The = study=20 participants agreed to

consume only=20 food provided by the

staff. = Participants included 459

adults = with=20 systolic blood pressure

of = less than 160=20 mmHg and dias-

tolic = blood=20 pressure of 80 to 95

mmHg. = Not all=20 participants had

high = blood=20 pressure. About half of

the = participants=20 were women and 60

percent were=20 African Americans.

day=E2=80=99s menu. It=20 also includes forms

to = track eating=20 habits, recipes, and

many = tips on=20 changing your diet.

For = example, the=20 tips on eating the

DASH = way=20 include:

=E2=80=A2 To increase=20 your servings of

fruits = and=20 vegetables to eight

per = day, try to=20 have two servings

of = fruits and/or=20 vegetables at

each = meal plus=20 one fruit and one

vegetable as a=20 snack.

=E2=80=A2 To increase=20 your dairy servings

to = three a day,=20 try to have one

low-fat dairy=20 serving at each

meal. = Try taking=20 lactase enzyme

pills = if you=20 have trouble digest-

ing = dairy=20 products.

=E2=80=A2 Choose=20 whole-grain foods to get

added = nutrients,=20 especially the B

vitamins.

=E2=80=A2 Use the=20 percent daily value on

food = labels to=20 compare products.

=E2=80=A2 Feed your=20 craving for sweets

with = fresh or=20 dried fruit or fruit-

flavored=20 gelatin.

=E2=80=A2 Use fresh,=20 frozen, canned, or

dried=20 fruits.

=E2=80=A2 Use fresh,=20 frozen, or no-salt-

added = canned=20 vegetables.

So go = ahead, try=20 the DASH diet

and = help lower=20 your blood pres-

sure. = One note,=20 though: if you have

high = blood=20 pressure and take med-

ication, you=20 should not stop your

therapy. Use the=20 DASH diet and

talk = to your=20 doctor about your high

blood = pressure=20 treatment.

The = DASH diet=20 fact sheet is

available from=20 the NHLBI

Information=20 Center (#4082, single

copy=20 free).

Additional=20 information is available

on = the Web at=20 http://dash.bwh.

harvard.edu.

(continued=20 from page 5)

Results showed=20 that both the

fruit/vegetable=20 and the combination

plans = reduced=20 blood pressure, but

the = combination=20 plan=E2=80=94the DASH

diet=E2=80=94had the=20 greatest effect. The

DASH = diet=20 reduced systolic blood

pressure among=20 all participants by

an = average of=20 almost 6 mmHg and

diastolic blood=20 pressure by about 3

mmHg. = For those=20 people in the

study = with high=20 blood pressure, the

results were=20 more dramatic: they

had an = average=20 decrease in systolic

blood = pressure=20 of 11 mmHg and

diastolic blood=20 pressure of 6

mmHg. = Further,=20 the reductions

came = fast=E2=80=94within=20 2 weeks of

starting the=20 eating plan.

To = help people=20 adopt the plan,

the = NHLBI has=20 developed a fact

sheet = that=20 explains how to change

to the = DASH=20 diet. The booklet

includes a=20 detailed 7-day menu plan

with = specific=20 foods, serving sizes,

and = nutritional=20 assessment of each

The DASH=20 diet reduced=E2=80=A6

blood=20 pressure among all

participants=E2=80=A6=20 Further, the

reductions=20 came fast=E2=80=93within

2 weeks of=20 starting the eating

plan.

Page = 7

HEARTMEMO

WINTER = 1999

HeartFile:=20 NHBPEP

O L = L O W I N=20 G T H E

A S = H

I E = T

The = DASH eating=20 plan shown below is based on 2,000 calories a day. The number of daily = servings=20 in

a food = group may=20 vary from those listed, depending on your caloric needs.

Use = this chart to=20 help plan your menus, or take it with you when you go to the=20 store.

Food=20

Group

Grains = &=20

grain=20 products

Vegetables Fruits

Low-fat = or

fat-free=20 dairy

foods

Meats, = poultry,=20

&=20 fish

Nuts,=20 seeds,

& = dry=20 beans

Fats = &=20 oils**

Sweets

Daily=20

Servings

(except as=20 noted)

7-8

4-5

2-3

2 or=20 less

4-5 = per=20 week

2-3

5 per=20 week

Serving=20

Sizes

1 = slice=20 bread

1 / 2

cup = dry=20 cereal*

1 / 2

cup = cooked rice,=20 pasta, or

cereal

1 cup = raw leafy=20 vegetable

1 / 2

cup = cooked=20 vegetable

6 oz = vegetable=20 juice

6 oz = fruit=20 juice

1 = medium=20 fruit

1 / 4

cup = dried=20 fruit

1 / 2

cup = fresh,=20 frozen, or

canned = fruit

8 oz=20 milk

1 cup=20 yogurt

1 1 / 2

oz=20 cheese

3 oz = cooked=20 meats, poultry,

or=20 fish

1 / 3

cup or = 1

1 / 2

oz=20 nuts

2 = Tbsps or=20

1 / 2

oz=20 seeds

1 / 2

cup = cooked dry=20 beans

1 tsp = soft=20 margarine

1 Tbsp = low-fat=20 mayonnaise

2 = Tbsps light=20 salad dressing

1 tsp = vegetable=20 oil

1 Tbsp = sugar

1 Tbsp = jelly or=20 jam

1 / 2

oz = jelly=20 beans

8 oz=20 lemonade

Examples=20

and=20 Notes

whole-wheat=20 bread, English muffin, pita bread,

bagel, = cereals,=20 grits, oatmeal, crackers,

unsalted=20 pretzels, popcorn

tomatoes,=20 potatoes, carrots, green peas,

squash,=20 broccoli, turnip greens, collards, kale,

spinach,=20 artichokes, green beans, lima beans,

sweet=20 potatoes

apricots,=20 bananas, dates, grapes, oranges,

orange = juice,=20 grapefruit, grapefruit juice,

mangoes, melons,=20 peaches, pineapples,

prunes, raisins,=20 strawberries, tangerines

fat-free (skim)=20 or low-fat (1%) milk, fat-free or

low-fat=20 buttermilk, fat-free or low-fat regular or

frozen = yogurt,=20 low-fat and fat-free cheese

select = only=20 lean; trim away visible fats; broil,

roast, = or boil,=20 instead of frying; remove skin from

poultry

almonds,=20 filberts, mixed nuts, peanuts, walnuts,

sunflower seeds,=20 kidney beans, lentils, and

peas

soft = margarine,=20 low-fat mayonnaise, light salad

dressing,=20 vegetable oil (such as olive, corn,

canola, or=20 safflower)

maple = syrup,=20 sugar, jelly, jam, fruit-flavored

gelatin, jelly=20 beans, hard candy, fruit punch,

sorbet,=20 ices

Significance of=20 Each

Food = Group to=20 the

DASH = Eating=20 Plan

major = sources of=20 energy

and=20 fiber

rich = sources of=20

potassium,=20 magnesium,

and=20 fiber

important=20 sources of

potassium,=20 magnesium,

and=20 fiber

major = sources of=20 calcium

and=20 protein

rich = sources of=20 protein

and=20 magnesium

rich = sources of=20 energy,

magnesium,=20 potassium,

protein, and=20 fiber

besides watching=20 fats

added = to foods,=20 choose

foods = that=20 contain less fat

sweets = should be=20 low in

fat

* = Serving sizes=20 vary between

1 / 2

and=20 1

1 / 4

cups. = Check the=20 product=E2=80=99s nutrition label.

** Fat = content=20 changes the serving sizes for fats and oils. For example, 1 Tbsp of = regular=20 salad dressing equals 1 serving;

1 Tbsp = of a=20 low-fat dressing equals

1 / 2

serving; 1 Tbsp=20 of a fat-free dressing equals 0 serving.

Page = 8

summarizes=20 recent declines in choles-

terol = levels of=20 adolescents and adults,

presents the=20 results of recent clinical

trials = that=20 prove the benefits of choles-

terol = lowering=20 in primary prevention

and in = patients=20 with coronary heart dis-

ease = (CHD), and=20 highlights the critical

importance of=20 cholesterol lowering in

patients with=20 CHD. Educational pro-

gram = planners=20 are offered suggestions

on how = to use=20 the kit. New in this

year=E2=80=99s version=20 of the kit are education-

al = materials=20 developed especially for

women, = African=20 Americans, and Lati-

HEARTMEMO

WINTER=20 1999

HeartFile:=20 NCEP

AT = I O N A=20 L

H O = L E S T E=20 R O L

D U = C AT I O=20 N

O N = T=20 H

As = with=20 September of every year since

1989, = this past=20 September was desig-

nated = National=20 Cholesterol Education

Month. = To=20 support cholesterol educa-

tion = activities=20 in the month and

throughout the=20 year, the National Cho-

lesterol=20 Education Program (NCEP)

produced its=20 Cholesterol Kit =E2=80=9998. In

addition to a=20 variety of NCEP materi-

als, = the kit=20 contains an article that

nos. = The kit can=20 be found on the Web

by = going to the=20 NHLBI home page at

http://www.nhlbi.nih.gov. Hard = copies

of the = kit can=20 be ordered through the

NHLBI=20 Information Center while sup-

plies = last.=20 Cholesterol Kit =E2=80=9999 will be

available this=20 fall.

In = conjunction=20 with Cholesterol

Month, = on=20 September 1 the NCEP

launched an=20 interactive Web site,

=E2=80=9CLive Healthier,=20 Live Longer,=E2=80=9D which

was = developed=20 especially for people

with = heart=20 disease. See next page for

more = information=20 about the site.

Visitors to=20 this site may:

=E2=80=A2 Enter their=20 own LDL-cholesterol level and learn

what = their=20 physician is likely to prescribe to

lower = it to=20

=E2=89=A4100 mg/dL.

=E2=80=A2 Get an=20 estimate of their daily dietary allowances

for = saturated=20 fat, total fat, cholesterol, calories,

and = sodium based=20 on their height, weight, age,

sex, = and=20 activity level.

=E2=80=A2 Select=20 specific foods for meals and receive a

report = detailing=20 the amount of saturated fat, total

fat,=20 cholesterol, calories, and sodium for each

meal = and the=20 entire day. These totals are

compared with=20 daily dietary allowances.

=E2=80=A2 Learn how to=20 read food labels in the grocery

store.

=E2=80=A2 Learn how to=20 recognize serving sizes.

=E2=80=A2 Get=20 heart-healthy recipes.

=E2=80=A2 Understand how=20 drugs lower cholesterol.

=E2=80=A2 Take a=20 cholesterol and heart I.Q. test.

=E2=80=A2 Discover how=20 physical activity helps them stay = healthy.

The=20 National Cholesterol

Education=20 Program

I V = E

E A = L T H I E=20 R

,=20 L

I V = E

O N = G E=20 R

E=20 B

I T = E

Page = 9

HEARTMEMO

WINTER = 1999

HeartFile:=20 NCEP

N T = E R A C T=20 I V E

E=20 B

I T = E

: L

I V=20 E

E A = LT H I E=20 R

,=20 L

I V = E

O N = G E=20 R

The new = Web site=20 is designed to pro-

vide = accurate,=20 personally relevant

information to=20 help people with CHD

lower = their=20 LDL-cholesterol to the

goal = level of=20

=E2=89=A4100 mg/dL. = =E2=80=9CRecent

studies = have=20 proven that people with

CHD can = prevent=20 heart attacks and

actually prolong=20 their lives by lower-

ing = their blood=20 cholesterol levels,=E2=80=9D

says = Dr. James=20 Cleeman, NCEP coor-

dinator. =E2=80=9CThe=20 goal of the Web site is

to = transform=20 this health message into

simple = and=20 practical steps to success

in = cholesterol=20 lowering.=E2=80=9D

The = informative=20 site features

activities to=20 help people with CHD

eat = less=20 saturated fat and cholesterol,

become = more=20 physically active, lose

weight = if they=20 are overweight, and

adhere = to their=20 prescribed medical

regimen. The=20 Cyber Kitchen, Virtual

Grocery Store,=20 Cyber Cafe, Diet Cal-

culator, and=20 Virtual Fitness Room

offer = visitors a=20 fun, interactive way to

obtain = information on cholesterol

lowering. Dr.=20 Cleeman says more

attention to=20 cholesterol lowering is

needed = in=20 high-risk people with

CHD. = Although an=20 estimated 80 to

85 = percent of=20 people with CHD

would = benefit=20 from cholesterol lower-

ing by = diet or=20 drugs, only one-third to

one-half are=20 currently receiving

active = treatment. The =E2=80=9CLive Healthi-

er, = Live Longer=E2=80=9D=20 site can be found by

going = to the=20 NHLBI home page at

http://www.nhlbi.nih.gov. The = inter-

active = site is=20 currently under =E2=80=9CWhat=E2=80=99s

New=E2=80=9D and will=20 remain prominently

featured. See=20 box, left.

R ECENT C LINICAL T RIALS P ROVE B

ENEFITS=20 OF

C HOLESTEROL L OWERING

In the = past=20 year, there has been fur-

ther = clinical=20 trial evidence that con-

firms = the=20 benefits of cholesterol

lowering in=20 patients with and without

CHD. = The=20 Long-Term Intervention

with = Pravastatin=20 in Ischaemic Disease

(LIPID) study=20 examined the effects

of = cholesterol=20 lowering in people

with = CHD (those=20 who previously had

experienced a=20 myocardial infarction

[MI] = or=20 hospitalization for unstable

angina) and who=20 had relatively aver-

age = cholesterol=20 levels (median total

cholesterol 218=20 mg/dL, median LDL-

cholesterol 150=20 mg/dL). The LIPID

study = used the=20 HMG-CoA reductase

inhibitor=20 pravastatin to lower choles-

terol = levels in=20 the treatment group.

All = study=20 participants were counseled

about = following=20 a cholesterol-lower-

ing = diet. The=20 LIPID results showed

that = a drop of=20 18 percent in total cho-

lesterol and 25=20 percent in LDL-cho-

lesterol=20 produced a 24 percent

decrease in=20 deaths from CHD among

the = treatment=20 group compared with

the = control=20 group. Similarly, choles-

terol = lowering=20 in the treatment group

reduced total=20 mortality by 22 percent,

myocardial=20 infarction by 29 percent,

death = from CHD=20 or nonfatal MI by

24 = percent, the=20 need for coronary

revascularization by=20 20 percent, and

stroke by 19=20 percent. The benefits of

treatment in=20 reducing coronary events

were = observed=20 in all the study sub-

groups,=20 including patients with the

lowest baseline=20 LDL-cholesterol lev-

els.=20 Cholesterol lowering in the

LIPID = study=20 resulted in significant

reductions in=20 CHD-related deaths and

events = without=20 increasing non-CHD

deaths = from=20 cancer, trauma, or sui-

cide. = The LIPID=20 study was published

in the = November=20 5, 1998, issue of the

New = England=20 Journal of Medicine.

Another recent=20 clinical trial, the

Air = Force/Texas=20 Coronary Athero-

sclerosis=20 Prevention Study (AFCAPS/

TexCAPS), which=20 was published in

the = May 27,=20 1998, issue of the Jour-

nal of the=20 American Medical Associa-

tion,=20 studied cholesterol lowering in

generally=20 healthy people with no

clinical=20 evidence of CHD who had

relatively=20 average total cholesterol

(mean = of 221=20 mg/dL) and LDL-cho-

lesterol (mean=20 of 150 mg/dL) levels

and=20 below-average HDL-cholesterol

levels (mean of=20 36 mg/dL for men

and = 40 mg/dL=20 for women). This pri-

mary = prevention=20 trial used lovastatin,

an = HMG-CoA=20 reductase inhibitor,

along = with a=20 low-saturated-fat, low-

cholesterol=20 diet to lower cholesterol

levels. At year=20 1, total cholesterol

levels in the=20 treatment group were

lowered by 18=20 percent and LDL-cho-

lesterol levels=20 by 25 percent. The

AFCAPS/TexCAPS=20 results showed

that=20 cholesterol lowering reduced the

risk = for a=20 first-time major coronary

event = 37=20 percent. Major coronary

events included=20 fatal or nonfatal MI,

unstable=20 angina, or sudden cardiac

death. The risk=20 for MI was reduced

40 = percent,=20 unstable angina 32 per-

cent, = coronary=20 revascularization pro-

cedures 33=20 percent, coronary events

25 = percent, and=20 cardiovascular events

25 = percent. The=20 cholesterol-lowering

benefits in=20 this study extended to

both = men and=20 women as well as older

adults. There=20 were no significant dif-

ferences=20 between treatment and

placebo groups=20 in deaths from trauma

or = cancer or in=20 cancer incidence.

A = series of=20 recent statin trials has

now=20 demonstrated that cholesterol

lowering=20 significantly reduces CHD

In the=20 past year, there has

been=20 further clinical trial

evidence=20 that confirms the

benefits=20 of cholesterol low-

ering in=20 patients with and

without=20 CHD.

(continued=20 on page 10)

Page = 10

HEARTMEMO

WINTER = 1999

HeartFile:=20 NCEP

(continued=20 from page 9)

1988=E2=80=931994.=20 Saturated fat intake

decreased from=20 about 14 percent to

12 = percent of=20 calories in the same

timeframe.=20 Daily intake of choles-

terol = has also=20 declined in this age

group, from 350=20 mg in 1971=E2=80=931974 to

265 = mg in=20 1988=E2=80=931994.

NCEP=20 C

O = O R D I N=20 AT I N G

O = M M I T T=20 E E

E = E T I N=20 G

O = C U S E S=20 O N

A = N A G E=20 D

A = R=20 E

Managed care=20 was the focus of the

NCEP=E2=80=99s=20 Coordinating Committee

meeting held=20 this past June. Coordi-

nating=20 Committee members heard pre-

sentations from=20 representatives of the

managed care=20 industry, the National

Committee for=20 Quality Assurance

(NCQA), and the=20 Health Care Financ-

ing=20 Administration (HCFA).

Mr. = Jeff=20 Emerson, president and

chief = executive=20 officer of NYLCare,

told = the=20 committee that health care

costs = are=20 expected to continue to

increase for a=20 variety of reasons,

including: an=20 aging population; increas-

es in = technology without health care

planning;=20 increased costs of pharma-

ceuticals,=20 hospitals, and physicians; and

federally or=20 locally mandated benefits.

According to=20 Mr. Emerson,

approximately=20 50 percent of health

care = dollars=20 are currently spent by

endpoints in=20 four types of patients

covering the=20 range of risk for CHD:

those = with CHD=20 and high cholesterol

levels; those=20 with CHD and average

cholesterol=20 levels; those without

CHD = and with=20 high cholesterol lev-

els; = and those=20 without CHD and with

average=20 cholesterol levels. An

overview=20 analysis of 16 statin trials,

which = was=20 published in mid-1997,

showed that=20 cholesterol lowering pro-

duces = large and=20 highly significant

reductions in=20 CHD deaths and all

CHD = (nonfatal=20 heart attacks plus

CHD = deaths).=20 Among patients with

and = without=20 CHD, the analysis

showed that=20 cholesterol lowering sig-

nificantly=20 reduces cardiovascular dis-

ease = (CVD)=20 deaths, does not increase

non-CVD deaths=20 or cancer mortality

or = incidence,=20 and consequently pro-

duces = a=20 significant reduction in total

mortality.=20 These results provide pow-

erful = evidence=20 for the efficacy and

safety of=20 cholesterol lowering.

H = O L E S T=20 E R O L

E = V E L=20 S

E = C L I N E=20 I N

D = O L E S C=20 E N T S

A new = analysis=20 of data from the

National Health=20 and Nutrition Exami-

nation Surveys=20 shows that the average

total = cholesterol level in adolescents

12 to = 17 years=20 of age declined from

167 = mg/dL in=20 1966=E2=80=931970 to 160

mg/dL = in=20 1988=E2=80=931994. This 7 mg/dL

reduction is=20 somewhat smaller than

that = seen in=20 adults over the same peri-

od, = but the=20 overall trend is neverthe-

less=20 downward.

The = decline in=20 adolescents=E2=80=99 cho-

lesterol levels=20 coincides with a

decline in=20 intakes of saturated fat,

total = fat, and=20 cholesterol among 12-

to=20 17-year-olds. The average amount

of = fat consumed=20 by 12- to 17-year-

olds = dropped=20 from 37 percent of

calories in=20 1971=E2=80=931974 to approxi-

mately 34=20 percent of calories in

government=20 agencies, and it is

expected that=20 government spending

will = continue=20 to account for half of

all = spending.=20 In the near future, the

government will=20 become a larger

part = of the=20 health care system, and

as = such, will=20 wield more power to

direct future=20 efforts and act as a dri-

ving = force=20 behind new initiatives

and=20 technologies.

In = response to=20 rising health care

costs, Mr.=20 Emerson noted, most

employers have=20 tried to move into

managed care.=20 Current estimates are

that = 86 percent=20 of those covered by

insurance=20 participate in some type of

managed care=20 plan. In response,

managed care=20 organizations market

themselves to=20 employers in a variety

of = ways.=20 Recently, distinctions

among = plans=20 have been made in the

area = of quality=20 of care, as shown by

performance=20 measures and disease

state = management programs.

Because the=20 current and future

health care=20 markets are consumer-

oriented,=20 providing quality care con-

tinues to grow=20 more important.

Dr. = Cheryl=20 Warner, a clinical con-

sultant with=20 Harvard Pilgrim Health

Care = (HPHC),=20 offered a clinical

viewpoint on=20 adopting and imple-

menting=20 guidelines in the managed

care=20 environment. HPHC currently

has = cholesterol=20 screening and treat-

ment = guidelines=20 that were developed

by a = strategic=20 planning group of local

physicians. In=20 response to NCQA

requirements,=20 the screening guide-

lines = are=20 revised and disseminated to

both = members=20 and providers every 2

years.=20 Treatment guidelines are also

revised at=20 these times and are sent to

providers.=20 According to Dr. Warner,

HPHC = looks to=20 the NCEP for sci-

ence-based,=20 nationally accepted

guidelines that=20 are immediately trans-

ferable. When=20 implementing guide-

lines, health=20 plans must also consider

cost-effectiveness,=20 practice settings,

and = consumer=20 needs.

=E2=80=A6the=20 average total cholesterol

level in=20 adolescents 12 to 17

years of=20 age declined from 167

mg/dL in=20 1966=C5=931970 to 160

mg/dL in=20 1988=C5=931994.

Page = 11

HEARTMEMO

WINTER=20 1999

HeartFile:=20 NCEP

Dr. = Warner gave=20 examples of

implementation=20 strategies used for

cholesterol=20 screening guidelines:

=E2=80=A2 Communication=20 through newslet-

ters = and various=20 other forms of

education are=20 used to inform both

members and=20 providers about

screening=20 policies.

=E2=80=A2 In some cases,=20 automated

reminder systems=20 are used.

=E2=80=A2 Employees are=20 regularly offered

onsite = health=20 risk assessments and

interventions by=20 employers.

=E2=80=A2 Providers=20 receive aggregate and

provider-specific=20 outcome data,

primarily based=20 on the Health Plan

Employer Data=20 and Information

Set = (HEDIS)=20 measures, so that

they = can assess=20 their progress.

Dr. = Joseph=20 Thompson, vice presi-

dent = of NCQA,=20 stated that NCQA is a

private,=20 not-for-profit organization

run by = a widely=20 representative board.

It is = not part=20 of the managed care

industry or=20 HCFA. NCQA has three

main=20 constituency groups: consumers,

purchasers, and=20 delivery system rep-

resentatives.=20 Its mission is to enable

managed care=20 organizations to be

accountable by=20 providing information

on the = quality=20 of care they provide to

patients and=20 purchasers. NCQA has

two = major=20 activities: accreditation and

performance=20 review. The first looks at

how = health plans=20 ensure quality, and

the = second=20 measures the actual quality

of = care=20 provided.

Dr. = Thompson=20 explained that the

accreditation=20 review looks at several

major = areas=20 including quality

improvement and=20 preventive health

services.=20 Currently, NCQA requires

that = health=20 plans adopt and dissemi-

nate = guidelines.=20 The way in which

health = plans=20 develop and use guide-

lines = is=20 evaluated by the accredita-

tion = review=20 team: how the guidelines

relate = to the=20 clinical literature,

mechanisms for=20 updating and

reviewing the=20 guidelines, and how

the = guidelines=20 are disseminated.

Health plans=20 that cannot demonstrate

how = guidelines=20 are used and what

impact they=20 have on quality of care

do = not receive=20 full accreditation.

Dr. = Thompson=20 stated that HEDIS

performance=20 measures can be used

to = provide an=20 =E2=80=9Capples-to-apples=E2=80=9D

comparison of=20 performance among

health plans.=20 The draft for the next

round = of HEDIS=20 measures (1999)

includes two=20 cholesterol perfor-

mance = measures.=20 Coordinating Com-

mittee members=20 and Dr. Thompson

discussed=20 issues surrounding the

proposed=20 cholesterol measure for

target=20 LDL-cholesterol levels in

patients with=20 CHD. Coordinating

Committee=20 members voiced strong

support for the=20 implementation of a

HEDIS = cholesterol performance

measure that=20 uses an LDL-choles-

terol = of=20

=E2=89=A4100 mg/dL as the = treatment

goal = for CHD=20 patients. Citing a vari-

ety = of crucial=20 scientific and health

policy=20 shortcomings, Coordinating

Committee=20 members criticized an

NCQA = proposal=20 that would use an

LDL-cholesterol=20 target of

=E2=89=A4130

mg/dL = for CHD=20 patients.

Dr. = Jeffery=20 Kang, director of

HCFA=E2=80=99s Office=20 of Clinical Standards

and = Quality,=20 stated that when the Clin-

ton=20 administration was trying to imple-

ment = health=20 care reform, there were

three = underlying assumptions of what

was = needed:=20 managed competition, a

universal=20 budget, and universal cover-

age. = At=20 present, two of the three exist.

Universal=20 coverage is still lacking.

Dr. = Kang=20 reported that HCFA is

getting more=20 involved in managed

care. = HCFA has=20 a capitated payment

per=20 beneficiary. Participating man-

aged = care=20 organizations must provide

a = minimum set=20 of services for each

patient.=20 Outcome measures are needed

to = assess the=20 performance of health

plans = on a=20 population basis. HCFA is

interested in=20 performance measures

such = as those=20 used in HEDIS 3.0

because it can=20 use the measures to

hold = managed=20 care organizations

accountable for=20 both health care sta-

tus = and=20 individual clinical processes.

Performance=20 measures are also

used = by HCFA to=20 eliminate from

Medicare health=20 plans or providers

that = are not=20 meeting the measures.

This = process=20 drives quality improve-

ment = and=20 provides information about

what = works to=20 improve health status.

The = objective=20 is to bring the wide

distribution of=20 performance closer to

100 = percent.=20 Performance measure

reports are=20 also provided to the pub-

lic = so that=20 consumers have informa-

tion = about=20 quality of care.

Dr. = Kang stated=20 that one issue

surrounding the=20 achievement of per-

formance=20 measures is not a lack of

knowledge, but=20 behavior. For perfor-

mance = measures=20 to work, specific

providers need=20 to be aware of their

own = performance=20 so that they do not

overestimate=20 how often measures are

being = met.=20

The = NCEP=20 Coordinating Commit-

tee = plans to=20 continue working with

the = managed=20 care industry to devel-

op = strategies=20 for cholesterol screen-

ing = and=20 cholesterol lowering that

will = benefit a=20 large portion of

patients.

=E2=80=A6 HEDIS=20 performance

measures=20 can be used to

provide=20 an =E2=80=94apples-to-apples=E2=80=9C

comparison of=20 performance

among=20 health plans.

Page = 12

HEARTMEMO

WINTER = 1999

HeartFile:=20 Minority Populations

information,=20 have made CVD the lead-

ing = cause of=20 death among AI/ANs over

age = 45 today.=20 To foster a return to

healthy=20 traditions and reduce heart dis-

ease = among=20 AI/ANs, the NHLBI has

launched a new=20 initiative, =E2=80=9CBuilding

Healthy Hearts=20 for American Indians

and = Alaska=20 Natives.=E2=80=9D

The = goals of=20 the initiative are to

increase=20 awareness of the risk factors

that = cause CVD=20 and to promote heart-

healthy=20 lifestyles among AI/ANs

through=20 programming that is cultural-

ly = sensitive,=20 appropriate, and relevant.

The = task is=20 complex because, although

AI/ANs share=20 some similarities, there

are = also=20 substantial differences. Lan-

guages, health=20 care delivery systems,

and = behaviors=20 vary among communi-

ties = and=20 regions. And each tribe pre-

sents = a unique=20 pattern of risk factors,

diseases, and=20 culture.

An = NHLBI=20 background report clar-

ifies = the=20 health status of AI/ANs and

illuminates the=20 challenges and oppor-

tunities=20 involved. For example, it

explains that=20 data on AI/ANs are limit-

ed = because the=20 population has been

overlooked and=20 misclassified in the

past. = However,=20 the report also stresses

that=20 understanding and incorporating

AI/AN = traditions, such as the impor-

tance = of=20 extended families, can bolster

the = success of=20 community interven-

tions. The=20 report sets the stage for

action by=20 providing a profile of

AI/ANs,=20 including known demograph-

ics, = CVD=20 mortality and risk factors,

culture and=20 health perceptions, exist-

ing = health=20 promotion programs, and

recommended=20 strategies and models.

The = initiative=20 is targeting three

tribal=20 communities that were selected

based = on the=20 prevalence of CVD risk

factors and=20 other sociodemographic

characteristics.=20 Many of the people

in = the targeted=20 communities have

maintained=20 their native traditions and

language.

=E2=80=A2 The Ponca=20 tribe of Oklahoma has

about = 2,500=20 members in the north-

ern = central=20 part of the State. They

are = organized=20 in a clan system that

provides social=20 support and leader-

ship = and helps=20 preserve the tribe=E2=80=99s

traditions. The=20 tribe=E2=80=99s three lead-

ing = health=20 problems are diabetes,

alcoholism, and=20 heart disease.

=E2=80=A2 The Bristol=20 Bay Area Health Cor-

poration is a=20 nonprofit health care

provider that=20 serves people in 32

villages in=20 southwestern Alaska.

The = villages=20 are not connected by

roads, and the=20 area is very isolat-

O = M O R R O=20 W

=E2=80=99 S H

E = A LT=20 H

E = P E N D S=20 O N

O = D=20 AY

=E2=80=99 S I