TE recently spoke with Dr. Thomas Tenner, Chair of the Texas Council on Cardiovascular Disease and Stroke, and Maria Benedict, program specialist at the Texas Department of State Health Services, about the state’s Heart and Stroke Healthy City Recognition Program.
TE: Beyond the human toll on Texas families from cardiovascular disease and stroke, what are the economic costs?
Dr. Tenner: Cardiovascular disease across the U.S. in 2008 cost the country $297.7 billion and that is sort of a guesstimate in terms of direct cost of care as well as the indirect costs associated with loss of productivity of the individuals involved. That, of course, is a huge number, the kind of number we hear the government talking about all the time, you know, in terms of deficits and spending. It’s quite a significant amount of money just related to cardiovascular disease and death. And relative to Texas, just for hospitalizations in 2010, it was more than $19 billion, so we actually have a huge expenditure each year treating cardiovascular disease and stroke that occurs. The death rate from stroke in Texas was 44.9 percent in 2010, and many people survive, but have neurological damage. Those who experience neurological deficit require the rehabilitation and, of course, rehabilitation is a very costly process in an attempt to get these people back to functionability again. So, it’s a very high price tag.
TE: How is the Heart and Stroke Healthy Cities Recognition Program helping to increase awareness and lower risk for Texans, and what cities stand out for their efforts?
Maria Benedict: There’s been an evidence-based strategic effort to increase the awareness of heart disease, cardiovascular disease and stroke across Texas. Cities have taken the assessment results, they review the areas of weakness to strengthen and then develop an action plan to reduce the burden of cardiovascular disease and stroke in their community. For example, the Waco-McClellan County public health District’s “Eat Well Waco” developed a local dining guide. Many people eat meals outside of their homes, school or work environment. Developing and promoting a local dining guide may help to educate and guide residents to restaurants that offer healthy eating options such as low sodium foods or low fat foods. And down in the Valley, the Hidalgo County Health and Human Services and the city of Brownsville developed a stroke campaign that targeted rural and urban populations as well as English and Spanish-speaking residents in lower income areas. The Texas Department of State Health Services (TDSHS) provided organizations with a stroke public education campaign tool kit that was developed by goal three of the Texas Cardiovascular Disease and Stroke Partnership in 2010. The tool kit is located on the TDSHS website; anybody can access that. Additionally, Angelina County public health coalition out in Lufkin developed a comprehensive stroke education campaign utilizing the stroke tool kit. What makes this effort stand out is the strong relationship that the coalition developed with the media outlets including newspapers, TV stations and radio stations. Their coalition specifically targeted the Hispanic community, educated nursing and medical technicians students at Angelina College, in addition to the students in the police and fire academies. Angelina County earned the Cardiovascular Disease and Stroke Health Promotion award in 2011. Actually, I want to give a shout out to north Texas because Denton County Health Department under the direction of Dr. Bing Burton and Amber Haig who lead the Denton Healthy Community Coalition developed an impactful partnership with Tobacco-Free North Texas, and they’ve been steadfast in their tobacco cessation effort to become 100 percent smoke-free.
Dr. Tenner: That’s really important, because tobacco is the number one preventable cause of death in the U.S. Several hundred thousand people die as a result of smoking each year and tens of thousands from second-hand smoke. That’s one of the things that is sort of the low-hanging fruit - trying to get people to avoid tobacco use. And that’s one of the 10 criteria, as Maria will tell you.
TE: How were the criteria developed for assessing heart and stroke healthy cities in Texas?
Maria Benedict: Heart and Stroke Healthy Cities program was developed in 2003 under the leadership of the Texas Council of Cardiovascular Disease and Stroke with the help of other public and private organizations dedicated to reducing the burden of heart disease and stroke. There are 10 health indicators and they are evidence based. They’ve largely remained unchanged since their origin in 2003. The indicators one through five focus primarily on prevention whereas, six through 10 are more of a medical element to it, addressing CPR and AED use, cardiac and stroke event response and health care quality. The first five deal with prevention efforts. Is there a good comprehensive public information campaign? Is there physical activity promoted, access to healthy food, and we are looking at healthy schools and work sites? And so, the criteria right now are in the process of being reviewed for the 2012-2014-assessment cycle. The criteria change typically every two to three years. Now it’s every three years. The criteria that may be introduced may include breast-feeding initiatives, sodium reduction efforts and campaigns for decreasing screen times. We are having individuals that are experts in their field, and they’re going to provide feedback and evidence-based information and then we are going to update those criteria for the new assessment period.
Dr. Tenner: That’s very important because the 10 criteria are all based on data generated over the years across the nation recognized by organizations like the Heart Association and the CDC to be factors that can impact communities to help them to lower the incidence of cardiovascular disease. When we started out we thought these are 10 things that are important. But over the years, as Maria indicates, the criteria for those have been ratcheted down so that we are focusing on evidence-based actions to use in the criteria, in other words, we cannot set up programs that are not tested. They actually have to be programs that are known to reduce cardiovascular disease. One of the things is people talk about personal responsibility, which is, obviously, incredibly important, especially when it comes to behavioral change. But, the communities can present the population with heart and stroke healthy options. In other words, highlight those and increase awareness in the community so that whenever people do need to make those kinds of decisions they have a pretty good landscape of options to choose from.
TE: Are the local business communities involved in the Healthy Cities Program?
Maria Benedict: I started managing this program over a year and a half ago, and Heart and Stroke Healthy City encourages cities to develop relationships with their Chamber of Commerce. Many businesses are part of their local chamber and regardless of whether the businesses are large or small it’s important for businesses to promote or facilitate work site wellness initiatives. Strong work site wellness initiatives encourage employees to be physically active; promote healthy food choices in vending machines or cafeteria; they develop tobacco free work sites through policy, environmental or organizational changes. But no matter what type of environment, whether it’s work, play, school, private or public, people are healthier when the places where they work, live and play support good health.
Dr. Tenner: One of the aspects that I have noticed, over the years, is that whenever a city is recognized as gold, silver or bronze or honorable mention, we try to get a city council member to go to the council to present the award. It is interesting to watch these cities like Amarillo, Lubbock, and Abilene. They want to know what the other cities got. If they are not beating that city they want to know why. So, from being the 10 fattest cities, we are trying to go to the 10 Heart Healthy Cities and by getting this sort of competition, again, it increases awareness of the programs and, if we can get them fighting to be healthier than the other cities that would be a good thing.
Maria Benedict: It’s definitely healthy competition.
TE: I’ve seen references to what is described as “a cultural trap of bad behavior” in explaining why Texans are vulnerable to heart disease and stroke. What exactly does this mean?
Dr. Tenner: If you think about the generation of my parents who are part of the Great Generation, they actually came up in an environment of tobacco. We have really done a great job of diminishing the number of people who smoke. But cultural traps of bad behaviors are things like not exercising or still smoking. The high-fat and high-salt diet is actually a new culture, as pointed out in that HBO Weight of the Nation documentary. We are eating more processed foods; we are eating more fast foods. I was, actually, in D.C. yesterday visiting with the Heart Association, and we were discussing the issue that we are bombarded by commercials for these fast processed foods, very high, hard, if you will, calories but, you really don’t see a lot of advertisements for tomatoes and cucumbers, and, you know, the wonderfulness of spinach. And, so, what we end up with is we become acculturated to more of these fast foods, eating out, food-on-the-go. Those are not really healthy foods for us to have as a steady diet. I think that’s what I was thinking of when I used that term. We are actually sort of…It becomes acceptable in our culture or even desirable to be drinking Cokes and eating pizza and sort of having a steady diet for that when really those are actually fairly new in the human condition.
TE: All in all, are you optimistic we’ll turn things around here in Texas?
Dr. Tenner: I really am. You know it’s just like the tobacco issue. It’s not that people don’t want to choose to do the healthy thing. A lot of times it’s just a matter of being exposed to the information and, once you are exposed to the information, and again, science is a preponderance of evidence and, the evidence that we have accumulated to date say that smoking is not a good thing, not smoking is, exercising is a good thing, and sitting on the couch is not. As that preponderance of evidence accumulates, and we started having people getting interested in it, people will start to make the right choice. I actually ran into a lady in Washington, D.C. the other night and, she had on her jogging stuff and she was running. I was lost and I asked her how I could get back to the DuPont Circle area. And she said, “Actually, I’m finding out because I’ve decided I need to exercise.” She ended up telling me that she has been watching the HBO series on Weight of the Nation. So, she’s sitting there watching this and she said, “I’ve got to make some changes,” and she is attempting to make those changes. Now, behavioral changes are probably the hardest thing that we have to do as a society, but I think, as we get more and more information, I’m optimistic that people are going to look as that information say, you know, I need to be going in this direction, not that direction. I think it’s just a matter of getting the information to the people so they can take personal responsibility for those decisions.
Maria Benedict: I think, in addition to making proper healthy food choices and increasing physical activity is in creating an environment that is conducive to those kinds of activities so, having a work policy, allow 15 minutes of physical activity, you know. You could take a break or to have healthy vending machine options or a breast-feeding room for moms. Creating environments is also really important. I think as info becomes more readily available people understand “Oh, it’s not just the healthy choice that I need to make,” but also see it’s important to change their environments as well.
Dr. Tenner: Those are things that communities can do for their populations and, it’s not necessarily mandating this or that. It’s just putting an environment out there that enables people to have a healthy choice. In Lubbock if I decided to walk to work, I’m… it’s called “road kill,” you know. So having lanes or sidewalks where people could actually walk would be very helpful. You don’t have to walk, but if people wanted to do that, the environment, as Maria said, would be there or appropriate for doing that kind of activity. Those are the things that communities can do to help people do the right thing.