Editor’s Note: Dr. Tom Frieden is the former director of the US Centers for Disease Control and Prevention, and commissioner of the New York City Health Department. He is currently president and CEO of Resolve to Save Lives, a global non-profit initiative housed at Vital Strategies, working with countries to prevent 100 million deaths and make the world safer from epidemics. The views expressed in this commentary are solely those of the author.
Growing up, I watched my father, a highly respected cardiologist, read medical journals every evening, answer emergency phone calls in the middle of many nights, and rush to the hospital after-hours several times a week. I didn’t know it then, but these years were the peak of an epidemic of heart disease in the United States.
Cardiovascular disease was, and still is, our No. 1 killer. It’s a major source of our health care costs, and causes disability and related economic loss. At its peak, in the 1960s, among people over age 35, 1 in 100 died of heart disease every year – a rate more than two-thirds higher than today.
The decrease in cardiovascular disease has prevented 10s of millions of deaths and accounted, spectacularly, for three-quarters of the increase in life expectancy in the United States until 2010. The decline in life expectancy in the United States plateaued until 2014, decreased three years in a row from 2015 to 2017, then edged back up in 2018.
Why did heart disease decrease so rapidly for half a century? Why did that decrease stall? And, most importantly, what can we do to reduce it more? (Much more progress is clearly possible – the US heart disease death rate is nearly 20% higher than that of other high-income countries, and 75% higher than the rate in France.)
The best estimate is that about half of the decrease in cardiovascular disease came from public health interventions that reduced smoking, cholesterol and other risk factors, and the other half from improved medical care, particularly better treatment of hypertension and more effective care of people during and after a heart attack.
Why the decrease in heart disease deaths has slowed is less understood. Possible causes are increased obesity and lack of further progress decreasing blood pressure, cholesterol and sodium intake.
There’s a bottom line – or, actually three of them – one each for all of us, our clinicians and the government.
What you can do
All of us need to know and control our blood pressure – the lower the better, down to 120/80. For many of us – including me – that means medicine every day for the rest of our lives. People who have had a heart attack or stroke should take a statin. Others at risk are recommended to do so, although there are differing views of the potential population-wide benefit of cholesterol-lowering drugs.
No one should smoke cigarettes or inhale other people’s smoke.
We need to walk more – up stairs, outside, to and from work or school, basically anywhere we enjoy walking or can comfortably walk.
We need to find healthy food we like – vegetables, fruit, nuts, legumes, fish – and eat more of it. And we should consume less salt, and when we do use salt, use low-sodium salt and low-sodium soy sauce (except for people on a potassium-restricted diet).
What your doctor can do
Health care providers need to measure blood pressure in every adult, put everyone with hypertension on effective medications, and track patient progress until blood pressure is controlled. They must advise all tobacco users to quit, help them do so with medications and counseling, and become strong advocates for tobacco control. And they should not merely advise, but prescribe a healthy diet and regular physical activity.
What governments can do
Governments must incentivize primary care health systems to improve blood pressure and cholesterol control rates. Controlling blood pressure can save more lives than any other medical intervention among adults, but, for more than $3 trillion a year, the US health care system does this correctly only about half the time.
They must also raise tobacco taxes (the best way to keep people from smoking); ensure smoke-free public spaces and workplaces; make the image of tobacco use consistent with the reality – not glamorous, but disabling and disfiguring; help people quit; and implement other new anti-tobacco policies including those against e-cigarette use by kids.
And governments need to make healthy food readily available and affordable and ensure that only healthy food is served, sold or subsidized by the government or on government property.
These deaths can be avoided
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These aren’t the only drivers of heart disease. Stress, lead exposure, pollution, alcohol, depression, inadequate sleep, childhood trauma, obesity and more also contribute, though the relative importance of these factors and their interactions aren’t known definitively. But that shouldn’t stop us from acting now on the main factors we can change to prevent heart attacks and strokes – quitting smoking, eating healthy and controlling high blood pressure.
Every year, cardiovascular disease kills more than half a million Americans and disables millions more. The costs of health care to treat heart disease and stroke are astronomical, and the economic losses from disability and early death are even higher. Most of these deaths, and costs, can be avoided. All of us – our families, neighbors, friends, doctors and government – will benefit if we take these simple steps to a longer and healthier life.