Report from the Utah De

1. Heart Disease & Stroke In Utah,
2010
Robert T. Rolfs, MD, MPH
Director, Div. Disease Control and Prevention
State Epidemiologist
Utah Department of Health

2. Key Points
1. Utah and the US have experienced significant declines in
mortality from heart disease and stroke. Some factors that
contribute to this include population-wide lifestyle
changes, such as increased physical activity and decreased
cigarette smoking.
2. High blood pressure patients have a higher prevalence of
risk factors and co-morbidities compared to the general
population. The health care system is not adequately
controlling high blood pressure, despite widely available
and relatively inexpensive treatment options.
3. Sodium is emerging as an important for controlling high
blood pressure.

3. Burden of Heart Disease & Stroke in
Utah
• In 2008, 3,562 Utahns died of cardiovascular
disease, the leading cause of death in Utah.
• Average age at death from heart disease and
stroke:
– Males: 76 years old
– Females: 81 years old
Source: Utah Death Certificate Database, ICD 10 Codes I00-I78. Age-adjusted to the 2000 U.S Standard Population

4. Utah Heart Disease Deaths, 1999-2009
Mortality Rate Decreased by 29% Average Age at HD Death No change
in 11 years
250 80
78
200 76 77.98 77.9
191.75 74
150 72
70
135.54
100 68
66
50 64
62
0 60
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Source: Utah Death Certificate Database, ICD 10 Codes I00-I09, I11, I13, I20-I51. Age-adjusted to the 2000 U.S Standard
Population

5. Utah Coronary Heart Disease Deaths,
1999-2009
Mortality Rate Decreased by 44% in Average Age at CHD Death No change
140
11 years
80
120
118.27
Rate per 100,000 Pop.
100
75 77.37 76.22
80
70
60 66.34
40 65
20
60
0 1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Source: Utah Death Certificate Database, ICD 10 Codes I20-I25, I11. Age-adjusted to the 2000 U.S Standard Population

6. Utah Stroke Deaths,
1999-2009
Decreased by 41% in
Mortality Rate
11 years
70
60
61.32
Rate per 100,000 Pop.
50
40
30 36.01
20
10
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Source: Utah Death Certificate Database, ICD 10 Codes I60-I69. Age-adjusted to the 2000 U.S Standard Population

7. Utah Stroke Deaths
Avg. Age at Stroke Death Decreased by 2 years
over 11-year period.
80 80.6
78 78.7
76
74
72
70
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

8. Utah Hospital Discharges
1992-2008
70 Stroke CHD
60
50
54.22
Rate per 10,000 Pop.
40
51%
30 Decrease 26.59
20
16.83 13.69
10 19%
Decrease
0
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Source: Utah Death Certificate Database, ICD 9 Codes 430-434, 436-438 (cerebrovascular disease), 410-414, 429.2
(CHD), 428 (HF) . Age-adjusted to the 2000 U.S Standard Population

9. Status of Risk Factors in Utah
Cigarette Smoking Decreased by 41.3% in 19 years
18%
16%
14% 15.50%
12%
10%
8% 9.10%
6%
4%
2%
0%
Age-adjusted to 2000 U.S. Population. Source: Utah Behavioral Risk Factor Surveillance System

10. Status of Risk Factors in Utah
Recommended Physical Activity Increased by 7.2% in 8 years
60%
56.6%
50% 52.8%
40%
30%
20%
10%
0%
2001 2003 2005 2007 2009
Age-adjusted to 2000 U.S. Population. Source: Utah Behavioral Risk Factor Surveillance System

11. Status of Risk Factors in Utah
Overweight or Obesity Increased by 51.4% in 20 years
70%
60%
59.50%
50%
40% 39.30%
30%
20%
10%
0%
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Years 1989-2009 Years 1989-2008.
Age-adjusted to 2000 U.S. Population, adults 18+ only. Source: Utah Behavioral Risk Factor Surveillance System

12. Status of Risk Factors in Utah
Diabetes Increased by 89.2% in 19 years
8%
7%
6% 7.00%
5%
4%
3% 3.70%
2%
1%
0%
Age-adjusted to 2000 U.S. Population. Source: Utah Behavioral Risk Factor Surveillance System

13. Status of Risk Factors in Utah
Dr. Diagnosed High Blood Pressure Increased by 22.4% in 14 years
30%
25%
25.42%
20%
20.76%
15%
10%
5%
0%
1995 1997 1999 2001 2003 2005 2007 2009
Age-adjusted to 2000 U.S. Population. Source: Utah Behavioral Risk Factor Surveillance System

14. Status of Risk Factors in Utah
Dr. Diagnosed High Cholesterol Increased by 57.8% in 18 years
30%
25%
25.88%
20%
15% 16.40%
10%
5%
0%
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
Age-adjusted to 2000 U.S. Population. Source: Utah Behavioral Risk Factor Surveillance System

15. The Institute of Medicine Report on Hypertension
“A NEGLECTED DISEASE”: HIGH
BLOOD PRESSURE

16. High Blood Pressure
• Most common primary care diagnosis in the
US
• Affects about 23% of Utah adults
• Contributes to 45% of all cardiovascular
deaths in the US
• Accounts for 1 in 6 all US adult deaths
• Estimated direct and indirect costs, 2009:
$73.4 billion
Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and
Control Hypertension. Washington, DC: The National Academies Press.

17. A “Neglected Disease”
• The health impact and cost of high blood
pressure is well-documented.
• The risk factors that contribute to HBP are
highly prevalent.
• Evidence-based interventions to control HBP
are well established and relatively cheap.
• We are failing to translate our public health
and clinical knowledge into effective
prevention, treatment, and control.
Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control
Hypertension. Washington, DC: The National Academies Press.

18. Inadequate Primary Care
“Lack of physician adherence to HBP treatment
guidelines is a major problem and significant
reason for the lack of awareness, lack of
pharmacological treatment, and lack of
hypertension control in the United States.”
Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control
Hypertension. Washington, DC: The National Academies Press.

19. Inadequate Primary Care
• HBP control is inadequate even when patients
have access to health care and a usual place of
care.
• 86% of individuals with uncontrolled HBP have
a usual source of care and average 4.3
physician visits per year.
• Few physicians encourage patients to make
lifestyle modifications, such as healthy diet
and exercise, to control their HBP.

20. Inadequate Primary Care
• Physicians are unlikely to treat or to intensify
treatment for mild to moderate systolic HBP
(<165mmHg) if the DBP <90mmHg
• In one study, of those with a 24-month avg. BP
>140/90, 25% not diagnosed with HBP. 2/3 were
not diagnosed if BP was 140-59/<90.
• Of those on meds, the avg BP was 147/86, and
only 24% had HBP<140/90
• Few physicians encourage patients to make
lifestyle modifications that are known to be
effective in controlling HBP.
Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control
Hypertension. Washington, DC: The National Academies Press.

21. Patient Nonadherence
• 50% of patients discontinue drug treatment
after 1 year.
• Noncompliance with HBP meds = increased
hospital admissions.
• Continuous HBP medications = statistically
significant reductions in hospital expenditures
per patient that are greater than the
accompanying drug costs.
Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control
Hypertension. Washington, DC: The National Academies Press.

22. Patient Nonadherence
• 92% of persons with uncontrolled HBP have
insurance.
• Income and high out-of-pocket costs =
underuse of HBP medications
• Increased attention from providers in
identifying barriers to medication adherence
could help to address this.
Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control
Hypertension. Washington, DC: The National Academies Press.

23. HIGH BLOOD PRESSURE: THE
BURDEN IN UTAH

24. High Blood Pressure Prevalence
By Age and Sex, 2009
70%
60%
60% 55%
50%
40%
40% 34%
30%
21%
20% 14% 11%
10% 5%
0%
M F M F M F M F
18-34 35-49 50-64 65+
Source: Utah Behavioral Risk Factor Surveillance Survey

25. High Blood Pressure Diagnoses
2009
7,000
6,000
5,000
4,000
Count
3,000
2,000
1,000
0
Age <18 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
Group
Source: Utah All-Payer Database, ICD 9 Codes 401-405

26. High Blood Pressure Prevalence
By Education Level, 2009 By Income Level, 2009
35% 35% 33%
31% 30%
29% 29%
30% 30% 28%
25% 24% 23%
25%
20% 20%
15% 15%
10%
10%
5%
5%
0%
0%
Less H.S. Grad Some College
Than or G.E.D. Post High Graduate
High School
School
Source: Utah Behavioral Risk Factor Surveillance Survey. Age-adjusted to 2000 U.S. Standard Population.

27. High Blood Pressure Prevalence
By Ethnicity, 2005, 2007, 2009
30% 27.7%
25% 22.2% 22.4% 23.1%
20%
15%
10%
5%
0%
Hispanic or Latino White, non- Other, non- All Utahns
Hispanic Hispanic
Source: Utah Behavioral Risk Factor Surveillance Survey. Age-adjusted to 2000 U.S. Standard Population.

28. High Blood Pressure Prevalence
By Race, 2003, 2005, 2007, 2009
40%
34.6%
35%
30% 26.7%
25.3% 24.2%
25% 22.3% 21.4% 22.3%
20%
15%
10%
5%
0%
Amer. Ind. Asian Black Pac. Isl. White Other Total
Source: Utah Behavioral Risk Factor Surveillance Survey. Age-adjusted to 2000 U.S. Standard Population.

29. A Sentinel Indicator for Disparities
• Nationally, high blood pressure is associated with
racial and ethnic health disparities.
• These disparities occur along the entire spectrum
from risk factors to the delivery of medical care.
• Targeting interventions toward a general
population historically do not correct these
inequities and can even worsen them.
• Because HBP is so closely linked to other risk
factors associated with race and class, it can be
useful in measuring the effectiveness of
approaches to reduce health disparities.
Source: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control
Hypertension. Washington, DC: The National Academies Press.

30. HBP and Co-Occurring Risk Behaviors
Cigarette Smoking
18
16.1
16 15.1
14 13.2 13.2
1.4X
12 10.8
higher 1.6X
10 8.3 higher
8
6
4
2
0
Gen HBP Gen HBP Gen HBP
Total M F
Source: Utah Behavioral Risk Factor Surveillance Survey, 2005, 2007, and 2009 combined years. Age-adjusted rates.

31. HBP and Co-Occurring Risk Behaviors
Overweight or Obese
90 81.9
78.6
80 74.2
70 67.3 1.2X
1.3X
59.2 higher 1.5X
60 higher 50.6 higher
50
40
30
20
10
0
Gen HBP Gen HBP Gen HBP
Total M F
Source: Utah Behavioral Risk Factor Surveillance Survey, 2005, 2007, and 2009 combined years. Age-adjusted rates.

32. HBP and Co-Occurring Risk Behaviors
Meet Physical Activity Recommendations Not significantly
70
different from state.
60 55.7 56.2 54.8 55.2
52.1
48.4
50
40
30
20
10
0
Gen HBP Gen HBP Gen HBP
Total M F

33. HBP and Co-Occurring Risk Behaviors
Diabetes Increased 89.1% in 19
years
8%
7%
7.00%
6%
5%
4%
3.70%
3%
2%
1%
0%
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

34. Taking Medication to Control HBP
% Dr. Diagnosed HBP on meds
60%
54.5% 53.3% 54.3%
52.2%
50%
44.9%
40%
30%
20%
10%
0%
2001 2003 2005 2007 2009
Source: Utah Behavioral Risk Factor Surveillance System. Age-adjusted to 2000 U.S. Standard Population.

35. HBP in Utah: Conclusions
• Although HBP is associated with age, many factors
influence its distribution across other demographic groups.
Older, lower-income, less-educated, and racial and ethnic
minority populations bear a higher burden. Approaches
targeting the “general” population are unlikely to resolve
disparities.
• The health care system must use comprehensive evidence-
based approaches to support lifestyle change and medical
management to adequately address the high prevalence of
co-occurring risk factors and co-morbid conditions among
people with HBP.
• Public health agencies and partners must continue to
advocate for policies and processes that improve high
blood pressure prevention and control.

36. HBP in Utah: Conclusions
• HBP continues to be a challenging area for
state-level surveillance. We need to push for
increased access to clinic-level data, such as
blood pressure levels, in order to truly
estimate the prevalence and control of high
blood pressure.

37. “Knowing is not enough; we must apply.
Willing is not enough; we must do.”
-Goethe

38. Sodium Reduction: State and Local Action
Opportunities to Reform the Norm
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
38

39. Sodium Reduction: A Public Health Imperative
• Excess sodium intake is a primary risk factor for high
blood pressure.
• Most of the sodium in our food supply is invisible in
processed and restaurant foods. Consumers have little
control over the amount of sodium in their diet.
• It can be difficult for even the most motivated consumer
to reduce sodium intake.
IOM (Institute of Medicine). 2005. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and
39
Sulfate. Washington, DC: The National Academies Press.

40. Sodium and High Blood Pressure
• Increased sodium in the diet → increased blood pressure
→ increased risk for heart attack and stroke.
– Generally, lower consumption of salt means lower blood
pressure.
– Within weeks on average, most people experience a reduction in
blood pressure when salt intake is reduced.
• Even people with blood pressure in the optimal range
benefit from sodium reduction and reduced risk for heart
attack and stroke.
• Reducing sodium = reducing mortality.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
40

41. Sodium Reduction: A Public Health Imperative
• Sodium reduction can have a significant impact on
reducing disparities and cardiovascular disease events.
• Reducing sodium in the food supply is the best
population-based strategy to reduce the prevalence of
high blood pressure.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
41

42. Sodium Intake Recommendations
• The 2005 Dietary Guidelines for Americans recommend
less than 2,300 mg per day for the general population.
– For specific populations—70 percent of U.S. adults—limit intake
to 1,500 mg per day.
• Average daily sodium intake for U.S. adults is more than
3,400 mg per day.
IOM (Institute of Medicine). 2005. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate.
Washington, DC: The National Academies Press. Centers for Disease Control and Prevention. Application of lower sodium
intake recommendations to adults—United States,1999–2006. MMWR. 2009;58(11):281–3. U.S. Department of
Agriculture. What we eat in America. Available from http://www.ars.usda.gov/service/docs.htm?docid=15044 42

43. Sources of Sodium
Food processing
77%
Naturally
occurring
12%
At the table
6%
During cooking
5%
Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 4
3
Aug;10(4):383-93.

44. Why Action is Needed at State and Local Levels
• Strong scientific evidence supports the need for
population-wide sodium reduction due to the harmful
impact of sodium on blood pressure.
• Individual behavior change is difficult.
• The most effective population approach to reducing
sodium intake is to reduce the sodium content of
restaurant and processed foods, which contribute the
vast majority of sodium in the food supply.
• All current approaches are voluntary.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
44

45. Estimated Effects on HBP Prevalence
and Related Costs from Sodium Reduction
• Reducing average population intake to 2,300 mg per day
(current recommended limit) may…
– Reduce cases of HBP by 11 million.
– Save $18 billion in health care spending.
– Gain 312,000 quality-adjusted life years (QALYs).
• Even fewer cases of HBP and more dollars saved if intake
was reduced to 1,500 mg per day (recommended
maximum level for “specific populations”).
Palar K, Sturm R. Potential societal savings from reduced sodium consumption in the U.S. adult population.
Am J Health Promot. 2009 Sep-Oct;24(1):49-57. 45

46. Global Sodium Reduction
• Not just a public health issue for the United States.
– HBP is the primary contributor globally to heart disease and
stroke.
• Reformulation of products has occurred in other
countries.
– Sodium content of identical products in other countries can be
significantly lower.
• Some countries, such as the United
Kingdom, Australia, and Canada, are leading the way in
sodium-reduction efforts.
• Sodium reduction and tobacco control =
recommendations to improve health in developing
countries .
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool. 46

47. International: Product Variability
Burger King Double Whopper Kellogg’s Special K
Sodium per Sodium per Sodium per Sodium per
serving 100 gm serving 100 gm
Brazil 1,300 mg 349 mg Canada 270 mg 931 mg
Australia 1,153 mg 321 mg Mexico 260 mg 867 mg
US 1,090 mg 291 mg US 220 mg 710 mg
Germany 1,010 mg 285 mg France 200 mg 450 mg
Canada 980 mg 263 mg Italy 200 mg 450 mg
UK 875 mg 246 mg UK 100 mg 450 mg
Italy 819 mg 231 mg Turkey 200 mg 400 mg
47
World Action on Salt and Health.

48. What Has Been Done to Reform
the Norm Abroad?
Several countries have taken action on sodium reduction.
• Finland: The country’s initiatives have resulted in a significant
decrease in average population salt intake.
• United Kingdom: Average sodium intake in the population has already
been reduced by 360 mg.
• Australia: Salt database that includes more than 7,000 items
identified large variations in the salt content of similar products
offered by different companies.
• Canada: Sodium Working Group formed in 2007 to work on a national
strategy to reduce sodium consumption.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool. 48

49. National Salt Reduction Initiative
• New York City Department of Health and Mental Hygiene has
launched a nationwide effort to reduce the level of salt in
processed and restaurant foods.
• The partnership includes more than 40 cities, states, and public
health organizations.
• The department is working with food industry representatives
on a voluntary framework to reduce the salt in their products.
• Initial sodium reduction benchmarks have been set for 61
categories of packaged foods and 25 categories of restaurant
foods.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool. 49

50. What Has Been Done to Reform the Norm in the
United States?
• State and local activity:
– Communities Putting Prevention to Work.
– Los Angeles County.
• Baltimore City: Salt Reduction Task Force.
• Massachusetts and New York City: Procurement policies.
• Seattle/King County and others: Menu labeling.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
50

51. Sodium Landscape
• IOM’s “Strategies to Reduce Sodium in the United
States”.
– Lay the groundwork for action.
• Food and Drug Administration to review IOM
recommendations and work with other agencies and
organizations.
• Enhanced surveillance of sodium in foods and foods
consumed.
• Fiscal Year 2009 congressional language.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.

52. Potential State and Local Strategies
• Procurement policies (federal, state, local, organizational).
• Support voluntary reduction efforts that include benchmarks
and accountability (such as NYC).
• Labeling requirements.
• Venue-based approaches.
• Consumer awareness campaigns.
• Letter-writing campaigns.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.

53. Healthier Food Environment =
Healthier Population
• Changing the food environment gives consumers a
broader range of healthful foods from which to choose.
• Policy and environment strategies are effective at the
state and local level and help drive demand for federal
action.
• One of the most promising strategies to decrease the
prevalence of heart disease and stroke is to lower
sodium content of processed and restaurant foods.
• Sodium reduction will benefit most Americans.
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
53

54. Additional Resources
• CDC’s Division for Heart Disease and Stroke Prevention
Salt Web page
http://www.cdc.gov/salt
• Institute of Medicine, Strategies to Reduce Sodium in the
United States
http://www.iom.edu/sodiumstrategies
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
54

55. Additional Resources
• NYC’s National Salt Reduction Initiative
http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml
• Baltimore City’s Salt Reduction Task Force
Recommendations
http://www.baltimorehealth.org/info/2009_09_30_SaltTaskForceReport.pdf
• Seattle/King County’s Nutrition Labeling
http://www.kingcounty.gov/healthservices/health/nutrition/healthyeating/
menu.aspx
From Centers for Disease and Control (2010). Sodium Reduction Awareness Tool.
55