CardioVision 2020:CardioVision 2020: A Community Responds to A Community Responds to

the Lifestyle Syndromethe Lifestyle Syndrome

Thomas E. Kottke, MD, MSPHThomas E. Kottke, MD, MSPHInaugural Project DirectorInaugural Project Director

tkottke@comcast.nettkottke@comcast.net

Promoting and Enabling Healthy Choices:

Linking the Desire for Health with the Decisions & Tools that Support

Health

The BroadmoorColorado Springs, CO

December 6th-8th, 2004

Preventing cardiovascular disease through personal commitment & community action

CM862659-3

cardiovision2020.orgcardiovision2020.org

CardioVision 2020:CardioVision 2020:Produced by those who reside or Produced by those who reside or

work in Olmsted County, work in Olmsted County, Minnesota and have acted to Minnesota and have acted to

improve their own health and the improve their own health and the health of their families, friends, health of their families, friends,

and neighbors through personal and neighbors through personal commitment and community commitment and community

actionaction

To partner with clinicians and To partner with clinicians and community organizations to community organizations to develop information systems, develop information systems, environment, skills, and environment, skills, and encouragement needed to help encouragement needed to help individuals make informed individuals make informed choices that can lead to primary choices that can lead to primary and secondary prevention of and secondary prevention of cardiovascular diseasecardiovascular disease

To partner with clinicians and To partner with clinicians and community organizations to community organizations to develop information systems, develop information systems, environment, skills, and environment, skills, and encouragement needed to help encouragement needed to help individuals make informed individuals make informed choices that can lead to primary choices that can lead to primary and secondary prevention of and secondary prevention of cardiovascular diseasecardiovascular disease

CardioVision 2020CardioVision 2020MissionMissionCardioVision 2020CardioVision 2020MissionMission

1) Tobacco-free and zero exposure 1) Tobacco-free and zero exposure to environmental tobacco smoketo environmental tobacco smoke

1) Tobacco-free and zero exposure 1) Tobacco-free and zero exposure to environmental tobacco smoketo environmental tobacco smoke

2) Five servings of fruits and 2) Five servings of fruits and vegetables per day; only vegetables per day; only lean/extra lean meats and low lean/extra lean meats and low fat/fat-free dairy productsfat/fat-free dairy products

2) Five servings of fruits and 2) Five servings of fruits and vegetables per day; only vegetables per day; only lean/extra lean meats and low lean/extra lean meats and low fat/fat-free dairy productsfat/fat-free dairy products

3) Total serum cholesterol <200 3) Total serum cholesterol <200 mg/dL; low density lipoprotein mg/dL; low density lipoprotein <100 mg/dL for individuals with <100 mg/dL for individuals with coronary heart diseasecoronary heart disease

3) Total serum cholesterol <200 3) Total serum cholesterol <200 mg/dL; low density lipoprotein mg/dL; low density lipoprotein <100 mg/dL for individuals with <100 mg/dL for individuals with coronary heart diseasecoronary heart disease

CardioVision 2020CardioVision 2020Personal GoalsPersonal GoalsCardioVision 2020CardioVision 2020Personal GoalsPersonal Goals

4) Blood pressure <130 mm Hg 4) Blood pressure <130 mm Hg systolic and <85 mm Hg diastolicsystolic and <85 mm Hg diastolic

4) Blood pressure <130 mm Hg 4) Blood pressure <130 mm Hg systolic and <85 mm Hg diastolicsystolic and <85 mm Hg diastolic

5) 30 minutes of physical activity on 5) 30 minutes of physical activity on most, if not all, days of weekmost, if not all, days of week

5) 30 minutes of physical activity on 5) 30 minutes of physical activity on most, if not all, days of weekmost, if not all, days of week

CardioVision 2020CardioVision 2020Personal GoalsPersonal GoalsCardioVision 2020CardioVision 2020Personal GoalsPersonal Goals

To help the individual To help the individual achieve and maintainachieve and maintainthe behavior changes the behavior changes they desire...they desire...

To help the individual To help the individual achieve and maintainachieve and maintainthe behavior changes the behavior changes they desire...they desire...

...we have defined...we have defineda vision for Olmsted a vision for Olmsted County.County.

...we have defined...we have defineda vision for Olmsted a vision for Olmsted County.County.

• All public areas areAll public areas aresmoke-freesmoke-free

• No advertising or promotion No advertising or promotion of tobacco productsof tobacco products

• Youth are unable to purchase Youth are unable to purchase tobacco products from tobacco products from vendors in communityvendors in community

• All public areas areAll public areas aresmoke-freesmoke-free

• No advertising or promotion No advertising or promotion of tobacco productsof tobacco products

• Youth are unable to purchase Youth are unable to purchase tobacco products from tobacco products from vendors in communityvendors in community

Our Vision for TobaccoOur Vision for TobaccoBy the year 2020...By the year 2020...Our Vision for TobaccoOur Vision for TobaccoBy the year 2020...By the year 2020...

• All restaurants provide their customers All restaurants provide their customers with meal analysiswith meal analysis

• All grocery stores provide product All grocery stores provide product analysis for total fat, saturated fat, analysis for total fat, saturated fat, cholesterol, and sodiumcholesterol, and sodium

• Schools offer and promote foods and Schools offer and promote foods and beverages that meet Healthy People beverages that meet Healthy People 2010 recommendations2010 recommendations

• Goal foods cost less per calorie than Goal foods cost less per calorie than foods that are high in saturated fat, foods that are high in saturated fat, sodium, or sugarsodium, or sugar

• All restaurants provide their customers All restaurants provide their customers with meal analysiswith meal analysis

• All grocery stores provide product All grocery stores provide product analysis for total fat, saturated fat, analysis for total fat, saturated fat, cholesterol, and sodiumcholesterol, and sodium

• Schools offer and promote foods and Schools offer and promote foods and beverages that meet Healthy People beverages that meet Healthy People 2010 recommendations2010 recommendations

• Goal foods cost less per calorie than Goal foods cost less per calorie than foods that are high in saturated fat, foods that are high in saturated fat, sodium, or sugarsodium, or sugar

Our Vision for NutritionOur Vision for NutritionBy the year 2020...By the year 2020...Our Vision for NutritionOur Vision for NutritionBy the year 2020...By the year 2020...

• All residents of Olmsted County can All residents of Olmsted County can travel throughout the county on foot or travel throughout the county on foot or bicyclebicycle

• All residents of Olmsted County have All residents of Olmsted County have access to affordable and safe access to affordable and safe opportunities for physical activity opportunities for physical activity

• Affordable and attractive youth activity Affordable and attractive youth activity programs are available to all children and programs are available to all children and adolescentsadolescents

• Elementary and secondary school Elementary and secondary school curricula include daily physical activity at curricula include daily physical activity at all levelsall levels

• All residents of Olmsted County can All residents of Olmsted County can travel throughout the county on foot or travel throughout the county on foot or bicyclebicycle

• All residents of Olmsted County have All residents of Olmsted County have access to affordable and safe access to affordable and safe opportunities for physical activity opportunities for physical activity

• Affordable and attractive youth activity Affordable and attractive youth activity programs are available to all children and programs are available to all children and adolescentsadolescents

• Elementary and secondary school Elementary and secondary school curricula include daily physical activity at curricula include daily physical activity at all levelsall levels

Our Vision for Physical ActivityOur Vision for Physical ActivityBy the year 2020...By the year 2020...Our Vision for Physical ActivityOur Vision for Physical ActivityBy the year 2020...By the year 2020...

• All residents of Olmsted County All residents of Olmsted County with coronary heart disease, with coronary heart disease, congestive heart failure or critical congestive heart failure or critical risk factor levels for these two risk factor levels for these two conditions have access to a case conditions have access to a case management systemmanagement system

• All residents of Olmsted County All residents of Olmsted County with coronary heart disease, with coronary heart disease, congestive heart failure or critical congestive heart failure or critical risk factor levels for these two risk factor levels for these two conditions have access to a case conditions have access to a case management systemmanagement system

Our Vision for SecondaryOur Vision for SecondaryPreventionPreventionBy the year 2020...By the year 2020...

Our Vision for SecondaryOur Vision for SecondaryPreventionPreventionBy the year 2020...By the year 2020...

Coronary heart disease and strokeCoronary heart disease and stroke

Metabolic syndromeMetabolic syndrome(hypertension, diabetes, dyslipidemia)(hypertension, diabetes, dyslipidemia)

Life-style syndromeLife-style syndrome(too many calories in, too few calories out, physical inactivity, (too many calories in, too few calories out, physical inactivity,

tobacco use & exposure)tobacco use & exposure)

? ? originsorigins

? ? originsorigins

Diseases of the Diseases of the life-style syndromelife-style syndrome include include•heart disease,heart disease,•stroke,stroke,•cancer, cancer, •diabetes, diabetes, •chronic obstructive lung disease, chronic obstructive lung disease, •osteoarthritis, osteoarthritis, •depression, depression, •many other diseasesmany other diseases

Therefore,Therefore,CardioVision 2020 CardioVision 2020

focuses on lifestyle focuses on lifestyle

For how can we reassure the individual who For how can we reassure the individual who has a total serum cholesterol of 199 mg/dl has a total serum cholesterol of 199 mg/dl and a blood pressure of 130/80 mm Hg if and a blood pressure of 130/80 mm Hg if (s)he smokes tobacco, lives on deep-fried fat (s)he smokes tobacco, lives on deep-fried fat and believes that a physical activity program and believes that a physical activity program is season tickets to their favorite teams?is season tickets to their favorite teams?

Nine lessons from Nine lessons from CardioVision 2020CardioVision 2020Nine lessons from Nine lessons from CardioVision 2020CardioVision 2020

Special thanks to Rebecca HoffmanSpecial thanks to Rebecca HoffmanCardioVision 2020 Director of InterventionCardioVision 2020 Director of Intervention

www.RebeccaHoffman.comwww.RebeccaHoffman.com

Lesson 1Lesson 1

Risk patterns and risk Risk patterns and risk distribution are the distribution are the same in Olmsted same in Olmsted County as in the rest of County as in the rest of the United Statesthe United States

Population Meeting 0 to 5 CardioVision 2020 Goals* Population Meeting 0 to 5 CardioVision 2020 Goals* Olmsted County, Minnesota 1999Olmsted County, Minnesota 1999

Women MenAge

≥70

60-69

50-59

40-49

30-39

20-29100 50 0 0 10050

% meeting goals

4 3 2 1 05*tobacco, diet, physical activity, serum cholesterol and blood pressure*tobacco, diet, physical activity, serum cholesterol and blood pressure

Kottke et al. Mayo Clinic Proceedings. 2000Kottke et al. Mayo Clinic Proceedings. 2000

Expected Proportion of EventsExpected Proportion of Eventsby Number of Goals Metby Number of Goals Met

Olmsted County, Minnesota 2000-2019Olmsted County, Minnesota 2000-2019for CHD and CVD Eventsfor CHD and CVD Events

Women MenEvent

CHD

100 50 0 0 10050% of events

CVD

5 4 3 2 1 0

Lesson 2Lesson 2

CardioVision 2020 is CardioVision 2020 is making an impact.making an impact.

Program Awareness on Program Awareness on RDD SurveyRDD Survey

All p All p <<.0001.0001

Program Approval on RDD Program Approval on RDD SurveySurvey

P = NSP = NS

Reported Behavior Change Reported Behavior Change (RDD Survey)(RDD Survey)

P = .027P = .027

Lesson 3Lesson 3

The messenger is a key The messenger is a key component of the message.component of the message.

The following is an example of a The following is an example of a technically outstanding video that was technically outstanding video that was ineffective in engaging the populationineffective in engaging the population

The following video is less technically The following video is less technically sophisticated, but is more effective sophisticated, but is more effective

because it features a known because it features a known community leadercommunity leader

Lesson 4Lesson 4

If people are to climb If people are to climb on, they need to know on, they need to know that they can climb off.that they can climb off.

““Trialability”Trialability”

Post-BulletinPost-Bulletin

9-21-009-21-00

JanuaryJanuary

JulyJuly

AnnualAnnualprogressprogress

and needsand needsassessmentassessment

CardioVision 2020 Annual CycleCardioVision 2020 Annual Cycle

MonthlyMonthlymediamediaeventsevents 60-day campaigns60-day campaigns

•Tobacco control Tobacco control •Physical activityPhysical activity• NutritionNutrition•Know your numbersKnow your numbersKick-offKick-off

BoosterBoosterPrizesPrizes

Personal Behavior ChangePersonal Behavior Change

Environmental ChangeEnvironmental Change

CardioVision 2020 CardioVision 2020 General Model of InterventionGeneral Model of Intervention

Brief campaigns and Brief campaigns and clinical interventionsclinical interventions

Environmental Environmental changes that changes that

support personal support personal goals goals

Personal behavior changePersonal behavior changeto reduce riskto reduce risk

Environmental change Environmental change programsprograms

Lesson 5Lesson 5

If the time line is realistic, If the time line is realistic, big changes can be big changes can be accomplished.accomplished.

The North Karelia The North Karelia ProjectProject

(organized 1972)(organized 1972)

The North Karelia The North Karelia ProjectProject

(organized 1972)(organized 1972)

Three key messagesThree key messages• More fruits and vegetables, More fruits and vegetables,

less saturated fatless saturated fat• Tobacco-freeTobacco-free• Hypertension controlHypertension control

Three key messagesThree key messages• More fruits and vegetables, More fruits and vegetables,

less saturated fatless saturated fat• Tobacco-freeTobacco-free• Hypertension controlHypertension control

(search “Puska P”)(search “Puska P”)

Mortality from Coronary Heart DiseaseMortality from Coronary Heart DiseaseMen 35-64 years (1969-1994)Men 35-64 years (1969-1994)

Mortality from Coronary Heart DiseaseMortality from Coronary Heart DiseaseMen 35-64 years (1969-1994)Men 35-64 years (1969-1994)

Puska P:Puska P: Cardiovasc Risk Factors Cardiovasc Risk Factors

6:203-210, 1996 6:203-210, 1996

Cardiac death rates haveCardiac death rates havenow dropped by 83%!now dropped by 83%!

Cardiac death rates haveCardiac death rates havenow dropped by 83%!now dropped by 83%!

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AllAllFinlandFinland

AllAllFinlandFinland

NorthNorthKareliaKareliaNorthNorth

KareliaKarelia

/100,000/100,000/100,000/100,000

800800800800

700700700700

600600600600

500500500500

400400400400

300300300300

200200200200

100100100100

Predicted and Observed Decline in CHD MortalityPredicted and Observed Decline in CHD MortalityEastern Finland – Men 35-64 years (1972-1992)Eastern Finland – Men 35-64 years (1972-1992)

Predicted and Observed Decline in CHD MortalityPredicted and Observed Decline in CHD MortalityEastern Finland – Men 35-64 years (1972-1992)Eastern Finland – Men 35-64 years (1972-1992)

Vartiainen E et al: BMJ 309:23-27, 1994Vartiainen E et al: BMJ 309:23-27, 1994

Changes in risk factor Changes in risk factor levels explain changes in levels explain changes in

disease ratesdisease rates

Changes in risk factor Changes in risk factor levels explain changes in levels explain changes in

disease ratesdisease rates

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PredictedPredictedPredictedPredicted

ObservedObserved

%%%%

0000

10101010

20202020

30303030

40404040

50505050

60606060

Lesson 6Lesson 6

Improvement in the Improvement in the community health requires community health requires continuous effort, continuous effort, resources, leadership, and resources, leadership, and marketing.marketing.

Spring, 2003Spring, 2003

Visits to Visits to Cardiovision2020.org Cardiovision2020.org

in 2003in 2003

““Leadership”Leadership”

1.1. A position of authorityA position of authority

2.2. Initiative taken by any member of a Initiative taken by any member of a group to further the mutual interests group to further the mutual interests of that group of that group

LeadershipLeadership

““. . . Energizing [people] to . . . Energizing [people] to action.” (page 44)action.” (page 44)

““. . . Is biographical.”. . . Is biographical.”

““Leaders engender leadership Leaders engender leadership traits in others. They teach others traits in others. They teach others to be leaders.” (page 42)to be leaders.” (page 42)

New York: Harper Business, 1997New York: Harper Business, 1997

Lesson 7Lesson 7

The program needs to The program needs to go where the people go where the people are.are.

Zorba’s, Rochester, MinnesotaZorba’s, Rochester, MinnesotaZorba’s, Rochester, MinnesotaZorba’s, Rochester, MinnesotaCP1059786-55

The CardioVision 2020 runner indicates the entrée contains less than 1000 mg ofsodium and 500 or fewer calories, of which less than 7% come from saturated fat.

Lesson 8Lesson 8

Get data. Get data. Data help make the Data help make the case and guide the case and guide the

programprogram

70% prefer smoke-free!

Lesson 9Lesson 9

Take care of yourself. Take care of yourself. Take care of your family. Take care of your family. Take care of your friends Take care of your friends and co-workers. and co-workers. Self-care will save you Self-care will save you money. . .money. . .

. . . and the life . . . and the life you save may be your own!you save may be your own!

Yes, lifestyle is more than personal responsibility, but the solution doesn’t lie in blaming.

The solution to the obesity epidemic lies in personal commitment and community action.

Thank you and best wishes!Thank you and best wishes!Gold Camp Road Self-portrait, December 6, 2004

Preventing cardiovascular disease through personal commitment & community action

cardiovision2020.orgcardiovision2020.org

Suggested reading• Kottke TE, Roger V, Nguyen TT, Dale LC, Burnett JC Jr, Tajik AJ. CardioVision 2020: A

multidisciplinary cardiovascular disease prevention project. Eur Heart J Supplements 1999;1 (Suppl S):S14-S18

• Kottke TE, Brekke MJ, Brekke LN, Dale LC, Brandel CL, DeBoer SW, Hayes SN, Hoffman RS, Menzel PA, Nguyen TT, Thomas RJ. The CardioVision 2020 Baseline Community Report Card. Mayo Clinic Proceedings 2000; 75:1153-1159.Kottke TE, Aase LA, Brandel CL, Brekke MJ, Brekke LN, DeBoer SW, Hayes SN, Hoffman RS, Menzel PA, Thomas RJ. Attitudes of Olmsted County, Minnesota, residents about tobacco smoke in restaurants and bars. Mayo Clinic Proceedings 2001; 76:134-137.

• Kottke TE, Clark MM, Aase LA, Brandel CL, Brekke MJ, Brekke LN, DeBoer SW, Hayes SN, Hoffman RS, Menzel PA, Thomas RJ. Self-reported weight, weight goals, and weight control strategies of a midwestern population. Mayo Clin Proc 2002; 77:114-121.

• Thomas RJ, Kottke TE, Brekke MJ, Brekke LN, Brandel CL, Aase LA, DeBoer SW. Attempts at changing dietary and exercise habits to reduce risk of cardiovascular disease: Who's doing what in the community? Prev Cardiol 2002; 5:102-108.

• Kottke TE, Hoffman RS. Take the long view of health. Health Forum Journal July/August 2002; 45(4):28-32.

• Wu LA, Brekke LN, Brekke MJ, Hoffman RS, Kottke TE. The potential impact of CardioVision 2020 and three other risk factor scenarios on population rates of coronary heart and cardiovascular disease: a call to action. In: Frontiers in Cardiovascular Health. Eds. Khalla NS, Chockalingam A, Berkowitz HI, Singal PK. Kluwer Academic Publishers, Boston, USA, 2003.

• Kottke TE, Wu, LA, Hoffman RS. Economic and psychological implications of the obesity epidemic. Mayo Clinic Proc 2003; 78:92-94.

• DeBoer SW, Thomas RJ, Brekke MJ, Brekke LN, Hoffman RS, Menzel PA, Aase LA, Hayes SN, Kottke TE. Dietary Intake of Fruits, Vegetables and Fat in Olmsted County, Minnesota. Mayo Clin Proc, 2003;78:161-166.

• Kottke TE, Sierra Johnson G, Allison TG, Hoffman RS. Obesity: another wolf at the door? Clin Obs Gyn 2004;47(4):890-97.