New guidelines for cholesterol management spark controversy; faulty risk calculator could lead to over-prescribing statins

The American College of Cardiology and the American Heart Association released new guidelines for cholesterol management, a new formula to assess heart attack and stroke risk, and guidelines for lifestyle modifications and weight management to reduce heart attack and stroke risk.

“These guidelines will be helpful to all physicians and their patients, but they will be particularly relevant in Kentucky, where nearly 70 percent of Kentuckians are overweight or obese, we are the third highest state in rates of high blood pressure, five Kentucky counties are among the least active in the U.S. and the incidence of diabetes is above the national average,” Dr. Susan Smyth, director of the Gill Heart Institute at the University of Kentucky, said in an e-mail.

However, some experts have questioned the new guidelines, and the new formula for calculating cardiovascular risk appears to overstate the risk value used to determine who should receive cholesterol-lowering statin drugs.

"There may be no single perfect score that we can use to give statins the 'thumbs up' or 'thumbs down' for our patients without established cardiovascular disease," Smyth said. "Ultimately, physicians have many different tools at their disposal to evaluate CV risk in their patients, and they will review all of the available evidence to make a determination about who may be likely to benefit from statin therapy."

The new guidelines also change how statins should be prescribed. The drugs have been given to lower cholesterol to a specific numerical value, but now it is suggested that moderate to high doses of statins be given to patients who fall within four identified groups of patients who have been determined to get the most benefit from the drug:

• already diagnosed with heart disease or stroke
• with an LDL {"bad" cholesterol) of 190 mg/dL or higher, who may have genetic risk
• aged between 40 and 75, with Type 2 diabetes and high LDL levels, but without heart disease or stroke
• with an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher who are between 40 and 75, without heart disease or stroke, but with high LDL levels.  

Instead of focusing strictly on patients' LDL and total cholesterol, the new guidelines suggest physicians treat patients based on their overall risk of heart disease or stroke, of which cholesterol levels are just one part, according to the report.

The guidelines in the report also call for lifestyle modification, including adhering to a heart-healthy diet, which includes vegetables, fruits, whole grains, low-fat dairy, poultry, fish, beans and healthy oils and nuts; 30 to 40 minutes of exercise three to four times a week; avoidance of tobacco products, and maintenance of healthy weight.

The guidelines use a cardiovascular risk calculator that considers age, race, sex, diabetes, smoking habits, blood pressure and low HDL, or "good" cholesterol levels, among other considerations.

But a problem has been identified with the risk calculator, so worrisome that a past president of the College of Cardiology called for a halt to the implementation of the new guidelines, reports Gina Kolata of The New York Times. The calculator appears to overestimate the risk group so greatly, Kolata reports, that it could mistakenly suggest that millions more people should be candidates for statin drugs.

"It's stunning," the cardiologist, Dr. Steven Nissen, chief of cardiovascular medicine of the Cleveland Clinic, told Kolata. "We need a pause to further evaluate this approach before it is implemented on a widespread basis."

After an emergency, closed-door meeting on Saturday night, the two organizations that published the guidelines said "that while the calculator was not perfect, it was a major step forward, and that the guidelines already say patients and doctors should discuss treatment options rather than blindly follow a calculator," Kolata reports.

Dr Sidney Smith, the executive chairman of the guideline committee, told Kolata that "the association would examine the flaws found in the calculator and determine if changes were needed."

Two Harvard Medical School professors, Dr. Paul M. Ridker and Dr. Nancy Cook, had pointed out the calculator was not working among the populations it was tested on by the guideline makers a year earlier, during an independent review for the National Institutes of Health's National Heart, Lung, and Blood Institute, which originally developed the guidelines, Kolata reports.

Dr. Donald Lloyd-Jones, co-chairman of the guidelines task force and chairman of the department of preventive medicine at Northwestern University, told Kolata that "the committee thought the researchers had been given these results."

Ridker and Cook evaluated the calculator again after they saw the guidelines and found that it over- predicted risk by 75 to 150 percent, depending on the population, Kolata reports. They wrote in The Lancet, a British medical journal, that the miscalibration be "reconciled and addressed" before implementation, saying: "If real, such systematic overestimation of risk will lead to considerable over-prescription."

Some doctors are concerned that because many people are already "leery of statins, the public would lose its trust in the guidelines or the heart associations," Kolata reports. Currently, it is only obvious that those in the highest risk groups, such as those who have heart attacks, strokes or have diabetes, should take statins, she reports.

Kentuckians can act to protect against heart disease and stroke; half of preventable deaths occur in adults age 65 or younger

By Molly Burchett
Kentucky Health News

Nearly one on three deaths in the U.S. each year is caused by heart disease and stroke. At least 200,000 of these deaths are preventable, and nearly half of those preventable deaths are of people under 65, says a new report.

What can you do to stop heart disease and stroke from killing you? Change your health habits, says the federal Centers for Disease Control and Prevention's "Vital Signs" report. Changes can include quitting smoking, getting more physical activity and using less salt in your diet. Kentucky communities can also take preventive measures by creating healthier living spaces, such as smoke-free zones and safe places to exercise.

While the number of preventable deaths from heart disease and stroke has declined in people 65 to 74, it has remained virtually unchanged in those under 65, says the report. Men, particularly black men, are at a greater risk for dying early from these conditions. Overall, counties in Southern states, including Eastern and some parts of Western Kentucky, have the highest preventable death rates.

Map: Age-adjusted preventable death rates per 100,000 people from CDC "Vital Signs" 

To take action against the heart disease and stroke, risk factors should be considered. Adults in Kentucky have been found to have these risk factors for heart disease and stroke: high blood cholesterol, diabetes, overweight or obesity, not exercising regularly and not eating the suggested amount of fruit and vegetables.

If you have one of more of these risk factors, it is possible to reduce your risk of getting and dying prematurely from heart disease or a stroke. For example, you should work with your doctor on a treatment plan to control your high cholesterol and diabetes, and if you use tobacco, find resources to quit smoking.  It is also important to maintain a healthy diet and a weight, in addition to exercising for 2 hours and 30 minutes every week. (Click here to read more)

Seven Ky. communities get grants to reduce risks for chronic diseases among children and 'Invest in Kentucky's Future'

Seven diverse Kentucky communities are getting money to reduce the risk of chronic disease among Kentucky's youth. The initial grants announced Thursday are part of the Foundation for a Healthy Kentucky's new Investing in Kentucky’s Future initiative, a five-year, $3 million program.

“The health of our next generation is at stake,” said Susan Zepeda, CEO and president of the foundation. “Our goal is to help communities make positive changes in policies and service access that will help our children grow into healthy, productive adults. Regardless of the challenges, we want to help communities find new pathways to positive solutions.”

Community groups will use their initial grants to collect and analyze local health data. That analysis will guide development of innovative strategies for effective, sustainable measures to improve children's health. Those communities chosen for the initiative are:

• Clinton County School District, Albany: initial grant of $27,755 for the Clinton County Healthy Hometown Coalition. “We are thrilled that our community was chosen to participate in this important initiative,” Asst. Supt. Paula Little said. “The members of the Healthy Hometown Coalition are committed to helping children grow up in a physical, social, and cultural environment that supports good health habits. With help from the foundation, we can develop our capacity to make a lasting, positive change in our community.”

• Fitness for Life Around Grant County, Williamstown: initial grant of $21,643 for FFLAG and the Northern Kentucky Health Department. “We are pleased and excited to be given the opportunity to work with the Foundation for a Healthy Kentucky,” FFLAG Chairman Jeff Walters said. “We are a small group that has been working on improving the health of our community and we believe we’ve had a positive impact thus far. This grant will accelerate the process and the work that’s been started.”

• Foundation for Appalachian Kentucky, Hazard: initial grant of $32,558 for Perry County Wellness Coalition. “We’ve been working for several years to improve the menu and encourage better eating habits in and out of school,” said Linda Campbell, nutrition director at Perry County Schools. “It’s not as easy as changing a menu or just buying whole wheat bread. We’re changing a culture, and that’s not a simple thing. Working together, as a community, we can really start to make a difference. This grant from the Foundation for a Healthy Kentucky allows us to take the next steps toward helping our kids to become healthier.”

• Green River Area Development District, Owensboro: initial grant of $40,483 for Partnership for a Healthy McLean County. “The Partnership for a Healthy McLean County realizes the impact community organizations, schools, work sites and health care have on the health of families,” said Jiten Shah, executive director of the district. "Obesity is a major factor for many chronic diseases which can begin in childhood and continue into adulthood. "

• Kentucky Heart Foundation Inc., Ashland: initial grant of $19,245 for Healthy Kids, Healthy Communities in Ashland. “Investing in Kentucky’s Future is a perfect fit for the work of the Healthy Kids Coalition and gives us the opportunity to continue to work on policy, system and environmental changes to improve the health of children in Boyd and Greenup counties,” said Laura Patrick, coordinator of Healthy Kids, Healthy communities. “We know that this approach will help sustain change for years to come and what is great about it is that it is sustainable.”

• Kentucky River Community Care, Inc., Jackson: initial grant of $34,156. “This foundation grant will help Breathitt County plan more opportunities for youth and families to participate in healthy lifestyle activities,” said Bridget Turner, KRCC director of clinical services. “We need to develop a strategic plan to specifically address the many barriers that face our children and threaten their future. Education, prevention, behavioral health, physical health, nutrition, employment, substance abuse are a few of the issues that we are trying to deal with in our county.”

• Louisville Metro Department of Public Health and Wellness: initial grant of $34,160. “If we are ever going to realize a healthier future for our citizens, we must improve the health of our young people,” said Dr. LaQuandra Nesbitt, director of the department. “These funds from the Foundation for a Healthy Kentucky will facilitate a coordinated, systemic approach to overcome the health barriers that many of our youth face. The grant will allow us to formulate policies and strategies to improve health that are based on accurate data with buy-in from stakeholders across the community.”

Reducing chronic diseases to improve Kentuckians' health
 
Chronic diseases such as cancer, diabetes and heart disease, are those that last over time, decrease quality of life, increase the risk of early death and occur at higher rates in Kentucky than in surrounding states; substance abuse and some mental illnesses are also chronic diseases.

Kentucky’s children are at greater risk than most for chronic diseases, including high rates of obesity and smoking. When children grow up, they are at an increased risk for heart disease, cancer or stroke, and Kentucky is above the national average in deaths from these diseases.

The Investing in Kentucky's Future initiative will help Kentucky communities confront this cycle of problems. The foundation is encouraging local leaders to identify how best to engage the community in order to have the biggest impact.

“This is the first step in our multi-year approach, which will lead to implementation of permanent solutions for healthier communities,” said Zepeda. “We believe that by working together on the local level, civic leaders with vision can develop innovative strategies to improve the health of our children.”

More than 50 interested organizations responded to the foundation’s request for proposals in October last year, and 22 were invited to submit a full proposal. The foundation’s board of directors approved funding for seven as part of the initiative. Click here to read more about the foundation.

Kids' excessive salty snacks are linked to obesity, high blood pressure; new limits on school vending items may help

As new research shows that America's child-obesity epidemic is linked to eating too many salty snacks,  new federal regulations could ensure that vending-machine snacks in Kentucky's schools are healthier and lower in sodium.

Spurred by children eating too much salt and being too fat, "blood pressure in America's kids and teens has gone sky-high," creating a young generation at risk for serious health problems, including heart disease, stroke, reports Brian Alexander of NBC News.

“Kids eat far too much sodium,” the study's co-author, Dr. Stephen Daniels told NBC. “And they aren’t adding it at the table, and their parents aren’t putting it into food; they’re getting it through processed foods.” The research, published Monday in the journal Hypertension, links this rising blood pressure to children's increasing bod- mass index and sodium intake.

The "Smart Snacks in Schools" nutrition standards, announced last month by the Department of Agriculture, require any food sold in public schools to meet calorie, fat, sugar and sodium limits. The changes shouldn't be very significant for Kentucky students because the state already prohibits vending machine sales during the school day. And, a few existing state regulations, like fat content, are tougher than the federal changes and will remain in place, Sue Bartenfield, nutrition program manager for the Kentucky Department of Education, told Stu Johnson of the Kentucky Public Radio bureau in Frankfort. The new federal limits on calories and sodium are tighter, and the federal law will also keep vending machines shut down for a half-hour after school, Bartenfield told Johnson.

First major study of diet and strokes links fried, sugary Southern diet, low on fruits and vegetables, to increased risk

Genuine Kentucky fried platter:
Cornbread, fried catfish, fried green
tomatoes, fried apples and fried okra
(Photo from Ramsey's, Lexington)

By Molly Burchett
Kentucky Health News

People with a Southern diet, or one heavy on fried food and sugary drinks like sweet tea and soft drinks, are more likely to suffer a stroke, a new study finds.

It's the first big look at diet and strokes, and researchers say it might help explain people in the nation's "stroke belt" or southern states suffer more of them, reports Marilynn Marchione of The Associated Press.

These findings have important implications for Kentuckians because stroke accounts for 5.5 percent of Kentucky deaths each year and more than 81 percent of Kentucky adults eat fruit and vegetables fewer than 5 times a day, which is a indicator of risk for stroke:

Heart Disease and Stroke Risk Factors from federal Behavioral Risk Factor Surveillance System national survey	Ky.	U.S.
Eat fruits and vegetables less than 5 times/day	81.6	75.6
Overweight or obese	69.1	62.9
No moderate or vigorous physical activity	55.8	50.5
High total blood cholesterol	38.5	37.6
High blood pressure	30.0	27.8
Cigarette smoking	28.2	19.8
Diabetes	9.9	8.0

"We're talking about fried foods, french fries, hamburgers, processed meats, hot dogs," bacon, ham, liver, gizzards and sugary drinks, said the study's leader, Suzanne Judd of the University of Alabama in Birmingham.  For the study, a southern diet also included jerky, red meat, eggs, and whole milk.


Fried foods tend to be eaten with lots of salt, which raises blood pressure and sweet drinks increases risk for diabetes- both are known stroke risk factors, Judd said.

People who ate about six meals a week featuring these sorts of "Southern" foods had a 41 percent higher stroke risk than people who ate that way about once a month, researchers found.

In contrast, people whose diets were high in fruits, vegetables, whole grains and fish had a 29 percent lower stroke risk, reports Marchione.

"It's a very big difference," Judd said. "The message for people in the middle is there's a graded risk" — the likelihood of suffering a stroke rises in proportion to each Southern meal in a week. 

These findings were reported last week at the American Stroke Association conference. The study was launched in 2002 to explore regional variations in stroke risks and reasons for them.

Stroke death rates in Kentucky vary widely among counties. Here's a county map of the rates, from KentuckyHealthFacts.org, which has a county-by county list:

The map shows stroke rates in ranges per 100,000 population from 2003 through 2007. Purple counties had rates above 69; blue counties ranged from 52 to 69; turquoise were 44 to 52; light blue were 31 to 44 (the number that is about the national average), and tan were 18 to 31.

One S.C. county serves as incubator for state's efforts to battle weight problems, with some good results

PE teacher Sharon Williams, right,
leads morning exercises before
classes start at Bells Elementary.
(The State photo by Tim Dominick)

With nearly two-thirds of South Carolina deemed overweight or worse, lucky Colleton County got picked to be a test case for doing better. That is, for improving its chances to beat the state's already overwhelming rates of diabetes, heart disease and stroke and for helping to lower the state's $1.2 billion dollar medical bill. Lucky, because in 2010, the county was awarded almost a half million Eat Smart Move More grant by the BlueCross BlueShield of South Carolina Foundation to see if it could promote health eating and more physical exercise countywide. Joey Hollerman of The State newspaper in Columbia, S.C., reports that "the results have been striking," though he notes that changing obesity numbers is "like turning an aircraft carrier, it's a slow process." Mostly, he's talking about attitude and perseverance.

How does the county-wide program work on a daily basis? First, of course, you have to have buy-in, which this county did. Hollerman explains that now when children arrive at Bells Elementary School in the county seat of Walterboro, "they go straight to the gym and walk laps before heading to classrooms. Worshipers at Power of Faith Delivery Ministry harvest collards as well as souls, and fried chicken is discouraged at church dinners. The local farmers market has a sparkling new home and a system set up to accept cards from the Supplemental Nutrition Assistance Program." The Let’s Go, Eat Smart program and exercise programs are posted in schools, workplaces, grocery stores and churches.

So how, if the numbers aren't clear yet, how to measure if it's working? Well, only one fried chicken basket showed up at a recent church supper and the member who brought it ended up apologizing for her breach. On the day the reporter visited only the elementary school only one child in the entire first grade tried to slip through without selecting a fruit or vegetable. He was sent back and grabbed a plastic container of grapes from the Go (instead of the Slow or Whoa) food options, Hollerman reports. There are also anecdotes galore, including those of children, once on insulin, who are now fine without it.

South Carolin's BlueCross BlueShield recently awarded another grant to Eat Smart Move More, in part to continue the work in Colleton County but also to for expand it to other communities. (Read more)

Women who smoke triple their risk of dying early, but quitting early enough might just wipe out that risk

A new study of more than a million women found that smokers have more than triple the risk of early death than nonsmokers, and that quitting can virtually eliminate the increased risk. Smoking is still the most preventable cause of death in the United States and the United Kingdom.

The University of Oxford study, published this week in the British medical journal The Lancet, included 1.3 million women between the ages of 50 and 65, making it one of the largest ever conducted on smoking. At the start of the study, in 1996, 20 percent of the women were smokers, 28 percent were former smokers and 52 percent had never smoked. "Each of the women was registered in the U.K.’s national health system, so their deaths and cause of death were recorded," explains Alexandra Sifferlin of Time magazine. "By 2011, 66,000 had passed away." Researchers found that even smokers who smoked as few as nine cigarettes a day had twice the mortality rate of nonsmokers.

"More encouraging, however," writes Sifferlin, "was the positive effect that quitting seemed to have on the women’s life span. Those who quit smoking before they reached 40 avoided more than 90 percent of the increased risk of premature death from cigarettes, while women who stopped even earlier -- before age 30 -- avoided 97 percent of the added risk." (Read more)

Study: Stroke victims getting younger and, yes, risk factors include obesity, diabetes and high cholesterol

A study conducted on first-ever stroke patients in the Greater Cincinnati and northern Kentucky area may have some devastating repercussions for the nation. The results of the University of Cincinnati research, published this week in the online issue of Neurology, found that the average age of stroke victims has dropped and that this has great implications for lifetime disability. Study author Brett Kissela, MD, with the UC's College of Medicine explained that the rise in risk factors like diabetes, obesity and high cholesterol are the cause. Newswise reports that the study found that strokes among people under 55 made up a greater percentage of all strokes over time, growing from about 13 percent in 1993-94 to 19 percent in 2005. The study was funded by the National Institutes of Health.

"What [the study] means is that even though young people typically feel like they're healthy and that a stroke can't happen to them, the fact is that our study is evidence that that is not true," said Kissela.“The good news is that some of the possible contributing factors to these strokes can be modified with lifestyle changes, such as diet and exercise. However, given the increase in stroke among those younger than 55, younger adults should see a doctor regularly to monitor their overall health and risk for stroke and heart disease.” (Read more)

18 Kentucky hospitals cited as 'top performers' on accreditation board's annual list

Eighteen Kentucky hospitals have been included on the annual list of hospitals that have excelled at adhering to basic procedures for surgery and other treatment of common illnesses such as heart attacks, heart failure and pneumonia. The Joint Commission, the nation’s major hospital accreditation board, has released this year's list of 620 hospitals considered to be “top performers” for following recommended protocols at least 95 percent of the time. The top 18 percent of accredited hospitals make the list.

Among the Kentucky hospitals that qualified on all four measurements were Greenview Hospital in Bowling Green, Ephraim McDowell Regional Medical Center in Danville, St. Elizabeth Medical Center in both Florence and Fort Thomas, Central Baptist Hospital in Lexington.

Those qualifying in three categories were the Robley Rex Veterans Affairs Medical Center in Louisville (not in surgery) and the Appalachian Regional Hospitals in Harlan and Middlesboro (not in heart attack).

Qualifying in two categories were Twin Lakes Regional Medical Center in Leitchfield, Frankfort Regional Medical Center, the Hospital of Louisa and Jackson Hospital Corp., all for pneumonia and surgical care.

Recognized for pneumonia care were Parkway Regional Hospital in Fulton, Paul B. Hall Regional Medical Center in Paintsville, Logan Memorial Hospital in Russellville and the KentuckyOne Health Hospital in Martin.

Among behavioral-health hospitals, ranked on their in-patient psychiatric care, the Kentucky facilities on the list were the Universal Health Services facility in Bowling Green, the new Cumberland Hall Hospital in Hopkinsville.

According to Kaiser Health News, the Leapfrog Group, a nonprofit organization devoted to patient safety, aided in the rankings process, as did Consumer Reports. The Commission has its own metrics. It's worth noting that next month, Medicare will start using hospital quality rankings on its Hospital Compare website to set reimbursements. (Read more)

Report: Two-thirds of Kentuckians obese by 2030 if trends continue; cost to nation's future unquestionably high

Nearly two-thirds of adults in Kentucky will be obese by 2030 if rates continue to climb as they are now, an analysis reported Tuesday. The level of obesity, defined as being roughly 30 or more pounds overweight, is projected to reach 60.1 percent in Kentucky in 2030, up from 30.4 percent in 2011, according to an analysis commissioned by the nonprofit Trust for America’s Health and the Robert Wood Johnson Foundation. Nancy Hellmich and Laura Ungar of The Courier-Journal in Louisville report that if states’ obesity rates continue on their current trajectories, the number of new cases of type 2 diabetes, coronary heart disease and stroke, hypertension, and arthritis could increase 10 times between 2010 and 2020, and double again by 2030. Medical costs associated with treating preventable obesity-related diseases could increase by up to $66 billion per year by 2030, and the loss in economic productivity could be as high as $580 billion annually. (Read more)

The joint report also shows that states could prevent obesity-related diseases and dramatically reduce health care costs if they reduced the average body mass index (BMI) of their residents by just 5 percent by 2030. Doing so would spare millions of Americans serious health problems, and the country could save billions of dollars in health spending. See the interactive map showing how much improvement could be made if that small change were made here.

The report also features a series of joint policy recommendations from TFAH and RWJF, including full implementation of the Healthy, Hunger-Free Kids Act, protection of the federal health reform law's Prevention and Public Health Fund, and inclusion of additional physical education and activity components in the Elementary and Secondary Education Act. To download the full report, go here. 

Penny-per-ounce tax on sugar drinks could save $17 billion, cut consumption and prevent disease and death, academics say

More than $17 billion in medical costs over 10 years could be saved if sugared drinks were taxed at 1 cent per ounce, and it would prevent 95,000 cases of coronary heart disease, 8,000 strokes and 26,000 premature deaths, say researchers at Columbia University and the University of California.

The tax would mean an extra 12 cents per can or 20 cents per bottle, and would generate about $13 billion in annual tax revenue. The study, published in this month's HealthAffairs, found the consumption of sugary drinks, including soda, sports drinks like Gatorade and energy drinks like Red Bull, would be cut by 15 percent among adults ages 25 to 64.

"Even our conservative estimates show that a penny-per-ounce tax on sugar-sweetened beverages could substantially reduce the negative health and financial impacts of obesity, diabetes and cardiovascular disease," said Dr. Y. Claire Wang, assistant professor at the Mailman School of Public Health at Columbia  and lead author of the study. "Putting the money raised by the tax into efforts to prevent obesity and other health problems could potentially increase the impact of such a policy."

In 2009, Americans consumed 13.8 billion gallons of sugar-sweetened beverages, which translates to about 45 gallons per person. The average 20-ounce bottle of a sugar drink contains almost 17 teaspoons of sugar. (Read more)