Heart disease progress stalls to ‘stagnation’
Joyce Hunter-Knox and her colleagues have strapped blood pressure cuffs on thousands of arms and urged countless people with high readings to get help. They believe they have saved some lives.
Hunter-Knox is not a medical professional. She’s a barber who owns a shop catering mostly to African American men in Greenville, Mississippi.
As part of a program run by the state’s health department, she does her part to fight the nation’s bigger killer: cardiovascular disease. “I started seeing how sick people really were, and they were walking around and didn’t even know it,” she says.
Millions of Americans are walking toward early, preventable deaths because of heart attacks, strokes and related conditions, experts say. Progress against those killers has stalled after decades of dramatic strides.
People in some states, including Mississippi, die from heart disease in much higher numbers than those elsewhere. African Americans face outsize risks.
“We are at a point of real stagnation,” says David Goff, director of cardiovascular sciences at the National Heart, Lung, and Blood Institute.
The overall burden of cardiovascular disease – the broad category that includes heart attacks, strokes, heart failure and other heart and blood vessel conditions – “is actually getting worse in some states,” says Gregory Roth, an assistant professor at the Institute for Health Metrics and Evaluation at the University of Washington.
The prime suspects for this shift: obesity and diabetes.
The most likely cures: lifesavers such as blood pressure and cholesterol control, healthier diets, more physical activity, less smoking and greater access to health care.
“This is a completely preventable set of diseases,” Roth says. “We know what works.”
At first, a success story
Deaths from coronary heart disease – heart attacks and other consequences of clogged arteries – peaked in 1968, the heart institute says. If deaths had continued rising at the rates seen then, 1.7 million Americans a year would now die of such causes. Instead, the annual death toll is closer to 400,000. Strokes kill an additional 140,000. That decline is “one of the greatest public health successes in history,” Roth says.
The initial decline was so steep, it was hard for some scientists to believe, Goff says. In 1978, experts gathered at the institute, part of the National Institutes of Health in Bethesda, Maryland, to argue about whether it was real. After much debate, they decided it was.
“It’s important to recognize that up until the mid-’60s, heart disease death rates had been going up and up and up,” and many scientists believed they would keep going up, Goff says. Heart disease was long seen as the price of aging – of being lucky enough to live in an era where fewer people died young from infectious diseases.
But big changes were happening. From 1950 to 1996, annual death rates fell 56% for heart disease and 70% for stroke, according to a recent review by institute scientists.
In hindsight, it’s easier to see why, Goff says. Americans ate less lard and more fruit, smoked fewer cigarettes and benefited from advances in medicine, such as bypass surgery, stents for clogged arteries and medications for cholesterol and high blood pressure.
Then, signs of trouble emerged.
Bad news adds up
In the first decade after 2000, cardiovascular deaths fell at a yearly clip of 3.7% for men and 4% for women, according to a study published in JAMA Cardiology. Then, something changed: From 2011 to 2014, the yearly rate of decline fell to just 0.23% for men and 1.17% for women.
In late 2016, the Centers for Disease Control and Prevention made a sobering announcement: U.S. life expectancy, long buoyed by plunging heart deaths, had fallen amid rises in drug overdoses and suicide in 2015. Life expectancy fell again in 2017. The plateau in heart deaths made a bad situation worse.
More bad news: The heart disease death rate in 2017 did not budge from the year before, and the stroke death rate inched up, the CDC reported.
Roth looked at local and state patterns and found more worrisome signs. The overall impact of cardiovascular disease, measured in years of healthy life lost to disability and death, increased from 2010 to 2016 in Indiana, Kentucky, Michigan, Mississippi, Missouri, New Mexico and South Dakota.
Even when hard-hit states, concentrated in the Southeast, made progress, they did not catch up with states, such as Minnesota and Colorado, where heart deaths are lowest, he found. County-to-county differences were even more stark.
“We don’t know for sure what’s causing it,” says Hilary Wall, a scientist at the CDC. “But we know for sure that obesity has been on the rise since the 1980s and diabetes kicked in in the 1990s.”
That timing makes them leading suspects for the plateau in cardiovascular deaths, Wall and Goff say. Obesity and diabetes are major risk factors for heart disease. They share many underlying causes, such as poor diet and inactivity.
Persistent geographic gaps suggest that unequal access to medical care and harder-to-measure socioeconomic differences share the blame, Roth says.
Deaths are preventable
“It’s so important to emphasize that heart attacks and strokes are preventable and that there are things we can all do that collectively will have a big impact,” Wall says.
The CDC is leading a five-year program called Million Hearts that aims to prevent 1 million heart attacks and strokes by reducing the large numbers of Americans who do not follow basic prevention steps. Those steps include controlling blood pressure and cholesterol, cutting salt, being physically active and quitting smoking.
Wall says 30% of adults in the United States get no physical activity – defined as moving enough to raise their heart rates for even 10 minutes a week. Fewer than half with high blood pressure have it under control.
Getting people to make and sustain such changes can be tough. HunterKnox has seen successes, such as the policeman who changed his diet, took up exercise and got his high numbers down.
And she’s seen tragedies, such as the family friend who stopped taking her blood pressure pills. “She had a stroke, and unfortunately, she died,” HunterKnox says.
Many people at increased risk for heart disease do not realize what a big killer it is, says Tonya Ware, 50, a survivor of cardiac arrest who lives near Jackson, Mississippi.
“My life would have been so different if someone had stood up at my church or one of my social groups and said more women die of heart disease than all cancers combined,” says Ware, a volunteer spokesperson for the American Heart Association.
African Americans are hit hard
African Americans died of heart disease at rates 21% higher than whites in 2015, according to the CDC.
“There’s a lot of unnecessary loss and sorrow … especially in the African American community, because we don’t have the information getting to us in the places where we really are,” Ware says.
Mammie Crowley-Maberry, 54, lives in Jackson and coordinates wellness programs as an executive assistant at the Mississippi Senate. She puts the problem this way: “You can’t help the people from a distance, because they just can’t hear you.”
Crowley-Maberry is a volunteer in the Jackson Heart Study, one of the nation’s largest studies of heart risk factors in African Americans. It’s a federally funded effort of the University of Mississippi Medical Center, Jackson State University and Tougaloo College.
Study organizers recently launched a community engagement arm, run by the state health department. The idea is to try a variety of grassroots prevention efforts and see what works, says Victor Sutton, director of the state’s office of preventive health and health equity.
“We didn’t get here overnight, and we are not going to turn the ship around overnight,” he says. But “if you can do it here in Mississippi, you can do it in a lot of places.”