Georgia 2002 CARDIOVASCULAR DISEASE REPORT T H E N U M B E R S B E H I N D G E O R G I A ' S LEADING CAUSE O F DEATH A N D DISABILITY contents T H E N U M B E R S B E H I N D G E O R G I A ' S LEADING CAUSE O F DEATH A EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. Leading causes of death in Georgia, 1999 CARDIOVASCULAR DISEASE MORTALITY IN GEORGIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. Figure 3. Figure 4. Figure 5. Table 1. Cardiovascular disease death rates in Georgia and the United States, 1980-1999 Cardiovascular disease death rates in Georgia, 1980-1999 Cardiovascular disease death rates in Georgia by race and sex, 1999 Cardiovascular disease deaths in Georgia by age group, 1999 Premature cardiovascular disease deaths by race and sex, Georgia, 1999 ISCHEMIC HEART DISEASE MORTALITY IN GEORGIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 6. Figure 7. Ischemic heart disease death rates in Georgia and the United States, 1980-1999 Ischemic heart disease death rates in Georgia by race and sex, 1999 STROKE MORTALITY IN GEORGIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 8. Figure 9. Figure 10. Stroke death rates in Georgia and the United States, 1980-1999 Stroke death rates in Georgia by race and sex, 1999 Stroke deaths by type, Georgia, 1999 HOSPITALIZATIONS FOR CARDIOVASCULAR DISEASE IN GEORGIA . . . . . . . . . . . . . . . . . . Figure 11. Cardiovascular disease hospitalizations, Georgia residents, 1999 MEDICAL PROCEDURES FOR CARDIOVASCULAR DISEASE IN GEORGIA . . . . . . . . . . . . . . Table 2. Number of cardiac catheterizations and open heart surgeries in Georgia, 1995-1999 CARDIOVASCULAR DISEASE STATISTICS BY COUNTY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 12. Figure 13. Table 3. Table 4. Cardiovascular disease death rates by county, Georgia, 1995-1999 Stroke death rates by county, Georgia, 1995-1999 Cardiovascular disease deaths, age-adjusted mortality rates, and hospitalizations by county, G Cardiovascular disease deaths, age-adjusted mortality rates, and hospitalizations by health dis CARDIOVASCULAR DISEASE RISK FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 14. Figure 15. Figure 16. Figure 17. Table 5. Percentage of Georgians reporting current smoking, 1984-1999 Percentage of Georgians reporting high blood pressure and percentage reporting high blood Percentage of Georgians reporting no regular physical activity and percentage overweight or Daily serving of fruits and vegetables consumed by Georgians, 1998 Body mass index table CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . THE PAUL COVERDELL NATIONAL ACUTE STROKE REGISTRY . . . . . . . . . . . . . . . . . . . . . . . REDUCE YOUR RISK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 A N D DISABILITY . . . . . . . . . . . . . . . . . . . . .3 . . . . . . . . . . . . . . . . . . . .4 . . . . . . . . . . . . . . . . . . . . .5 acknowledgments THIS REPORT WAS PREPARED JOINTLY BY THE GEORGIA DEPARTMENT OF HUMAN RESOURCES, DIVISION OF PUBLIC HEALTH AND THE AMERICAN HEART ASSOCIATION, SOUTHEAST AFFILIATE . . . . . . . . . . . . . . . . . . . . .7 . . . . . . . . . . . . . . . . . . . . .8 . . . . . . . . . . . . . . . . . . . . .9 . . . . . . . . . . . . . . . . . . . . .9 . . . . . . . . . . . . . . . . . . . .10 Georgia, 1995-1999 strict, Georgia, 1995-1999 . . . . . . . . . . . . . . . . . . . .15 cholesterol, 1984-1999 r obese, 1984-99 . . . . . . . . . . . . . . . . . . . .19 . . . . . . . . . . . . . . . . . . . .19 . . . . . . . . . . . . . . . . . . . .20 . . . . . . . . . . . . . . . . . . . .21 . . . . . . . . . . . . . . . . . . . .21 AMERICAN HEART ASSOCIATION, SOUTHEAST AFFILIATE Nettie Jackson, Advocacy ManagerGeorgia John Smiles, Director of Communications GEORGIA DEPARTMENT OF HUMAN RESOURCES Jim Martin, Commissioner Division of Public Health Kathleen E.Toomey, M.D., M.P.H., Director Chronic Disease Prevention and Health Promotion Branch James H. Brannon, M.S., M.Ed., Director Health Promotion Section Judith K. Griffith, R.N, M.S., Director Epidemiology Branch Paul Blake, M.D., M.P.H., Director Chronic Disease, Injury, Environmental Epidemiology Section Kenneth E. Powell, M.D., M.P.H., Chief Suggested citation: Mertz KJ, Jones NH, Griffith JK, Powell KE. Cardiovascular Disease in Georgia, 2002. Georgia Department of Human Resources, Division of Public Health and the American Heart Association, Southeast Affiliate, February 2002. Publication number DPH02.24HW. Further information on this report or on the two organizations can be obtained by contacting: Nettie Jackson Advocacy ManagerGeorgia American Heart Association, SE Affiliate 1101 Northchase Parkway, Suite 1 Marietta, GA 30067 678.385.2075 Internet: www.americanheart.org Julianne Roach Health Initiatives Manager American Stroke Association 1101 Northchase Parkway, Suite 1 Marietta, GA 30067 678.385.2055 julianne.roach@heart.org Kristen Mertz, M.D., M.P.H. or Nkenge Jones, M.P.H. Georgia Department of Human Resources Division of Public Health, 14th Floor 2 Peachtree Street, NW Atlanta, GA 30303 404.657.3103 Internet: http://health.state.ga.us 2 execustuivme mary > Cardiovascular disease (CVD), including heart disease and stroke, was the number one killer of Georgians in 1999, accounting for 39% of all deaths. > More than 24,000 Georgians died from CVD in 1999. > The CVD death rate in Georgia was 14% higher than the national rate in 1999. > CVD kills more women than men in Georgia; although the age-adjusted CVD mortality rate is higher for men, the actual number of deaths is higher for women because there are more elderly women than men. > For both men and women in Georgia, age-adjusted CVD death rates are higher for blacks than whites. > The majority of CVD deaths in Georgia were classified as ischemic heart disease (43%) or stroke (18%). > Georgia had the tenth highest CVD mortality rate among the 50 states in 1999; for stroke in particular, Georgia had the sixth highest mortality rate among the 50 states. > CVD caused more than 128,000 hospitalizations in 1999 and more than $1.9 billion in hospital charges. > The high CVD death rates in Georgia may be caused by the high prevalence of preventable risk factors for heart attacks and stroke, such as smoking, high blood pressure, overweight, a lack of regular physical activity, and poor diet. > In the late 1990s, smoking rates increased among adults in Georgia; in 1999, 24% reported that they currently smoked. > In 1999, three fourths (74%) of adults in Georgia reported not being physically active on a regular basis. > Over half (58%) of all adults in Georgia were overweight or obese in 1999. > The high CVD death rates should alert Georgians to the importance of working together to facilitate regular physical activity, healthy eating, and smoke-free lifestyles. 3 introduction CVD is the leading cause of death in Georgia and the United States C ardiovascular disease (CVD) includes all diseases of the heart and blood vessels, including ischemic heart disease (caused by narrowing of the coronary arteries, which reduces blood flow and oxygen to the heart), stroke, congestive heart failure, hypertensive disease, and atherosclerosis. CVD is the nation's leading killer of both men and women in all racial and ethnic groups. Each year in the United States, about 950,000 people die from CVD, which accounts for approximately 41% of all deaths.1,2 Almost 6 million hospitalizations each year are due to CVD. 1 According to the American Heart Association, CVD is a leading cause of disability in the nation. In Georgia, CVD caused 24,274 deaths in 1999, 39% of all deaths that year (Figure 1). Ischemic heart disease and stroke accounted for about 61% of CVD deaths. Death and disability from CVD are related to a number of risk factors, including smoking, high blood pressure, high blood cholesterol, a lack of regular physical activity, overweight, and poor nutrition.The adoption of a healthier lifestyle can lower the risk for developing CVD or reduce the severity of existing disease. This report describes the burden of CVD in Georgia. Its purpose is to present a brief overview of CVD death rates during the past two decades, including rates of ischemic heart disease and stroke; to report county-specific death rates; to report the number of CVD, ischemic heart disease, and stroke hospitalizations for Georgia residents; and to describe the prevalence of CVD risk factors in Georgia. Figure 1. Leading causes of death in Georgia, 1999 Cancer 21% IHD 43% Unintentional injury 5% Chronic respiratory 5% Diabetes 2% Kidney disease 2% Alzheimer's 2% Flu/Pneumonia 2% CVD 39% Heart Failure 8% Other CVD 31% Other 22% CVD = Cardiovascular disease IHD = Ischemic heart disease Stroke 18% 4 CARDIOVASMCOURLTAARLDITISYEIANSEGEORGIA Cardiovascular disease death rates have declined in both Georgia and the U.S. during the past 20 years (Figure 2). The causes of the decline are debated but presumably are related to the decline in cigarette smoking during the 1980s, improved blood pressure control, and improvements in medical care. Among the 50 states in 1999, Georgia had the tenth highest CVD death rate. Although the Georgia CVD death rate continues to decline, the rate of decline is slowing. From 1980 through 1992, the CVD death rate declined by an average of 2.4% per year. In contrast, from 1992 through 1998, the average annual decrease slowed to only 1.0% per year (Figure 3). Over the entire time period, 1980 through 1999, Georgia's CVD death rate was consistently above the U.S. rate and the gap is widening; Georgia's rate was 5% above the U.S. rate in 1980 and 14% above the U.S. rate in 1999. CVD death rates differ by sex and race; blacks have higher rates than whites and men have higher rates than women. In 1999, the CVD death rate in Georgia was 23% higher for black males than white males and 26% higher for black females than white females (Figure 4).The reasons for higher rates among blacks are not well understood, but they may be a result of a higher percentage of blacks with high blood pressure, or a higher percentage living in poverty with associated factors of poor diet or decreased access to health care. As stated above, males have a higher risk than females for dying from CVD. In 1999, the age-adjusted CVD death rate was 475 per 100,000 standard population for men and 343 per 100,000 standard population for women. However, 11,223 males and 13,050 females in Georgia died from CVD. More women die from CVD because women live to older ages when CVD is more common. CVD, however, is not just a disease of old age.The process of arterial narrowing, which causes heart attacks and strokes, may begin in the teenage years.3,4 The age at which blocked arteries actually kill varies greatly, and death can occur before old age. Of persons in Georgia who died from CVD in 1999, 22% were younger than 65 years of age (Figure 5). A greater percentage of blacks than whites die from CVD at ages less than 65 years (Table 1). Almost one half (42%) of black men who died of CVD in 1999 were younger than 65 years, whereas only 26% of white men who died of CVD were less than 65 years. Figure 2. Cardiovascular disease death rates in Georgia and the United States, 1980-1999 Age-adjusted death rate per 100,000 population 600 500 GA 400 300 US 200 100 NOTE. The vertical dotted line indicates a change in coding systems used for cause of death. ICD-9 codes were used for 1980-1998; ICD-10 codes were used for 1999 deaths. 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Age-adjusted death rate per 100,000 population Figure 3. Cardiovascular disease death rates in Georgia, 1980-1999 600 500 400 300 200 100 Average annual decrease of 2.4% per year Average annual decrease of 1.0% per year 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 NOTE. The vertical dotted line indicates a change in coding systems used for cause of death. ICD-9 codes were used for 1980-1998; ICD-10 codes were used for 1999 deaths. 5 Heart disease is often thought of as a "man's" disease. In terms of absolute numbers, however, there are more CVD deaths in females than males both nationwide and in Georgia. CVD is the leading cause of death for women, accounting for 42% of all female deaths in Georgia in 1999. Figure 4. Cardiovascular disease death rates in Georgia by race and sex, 1999 Age-adjusted death rate per 100,000 population 600 566.4 Black White 500 459.4 411.2 400 326.4 300 200 100 0 Males Females Figure 5. Cardiovascular disease deaths in Georgia by age group, 1999 Number of deaths 8000 7000 6000 5000 4000 3000 2000 1000 0 22% <45 45-54 55-64 65-74 75-84 85+ Age group in years Table 1. Premature cardiovascular disease deaths by race and sex, Georgia 1999 Black males White males Black females White females Total CVD deaths 2,842 8,361 3,402 9,618 No. (%) CVD deaths <65 yrs 1,199 (42.2%) 2,202 (26.3%) 828 (24.3%) 997 (10.4%) 6 IscMheOmRicThAeLarITt dYisIeNaseGEORGIA Ischemic heart disease, also known as coronary heart disease, refers to narrowing of the coronary arteries, which reduces blood flow and oxygen to the heart. Ischemic heart disease includes acute myocardial infarctions ("heart attacks") and complications resulting from previous myocardial infarctions. Of the 24,274 cardiovascular deaths in Georgia in 1999, 10,502 (43%) were from ischemic heart disease.The death rate from ischemic heart disease has decreased during the past 20 years (Figure 6), and unlike CVD overall, the average annual rate of decrease has continued at a steady pace. Also unlike total cardiovascular disease, Georgia's death rate from ischemic heart disease is below the national rate, ranging from 5% to 12% below the US rate each year (Figure 6). In Georgia, the age-adjusted death rate from ischemic heart disease was 1.7 times higher for men (227.5 per 100,000 standard population) than for women (132.0 per 100,000 standard population) in 1999. Among men, blacks and whites had a similar age-adjusted death rate in 1999 (Figure 7). Death rates for blacks tend to be higher than for whites in younger men (25 to 74 years) but higher for whites than blacks in the elderly (>75 years). Similar to overall CVD, the death rate from ischemic heart disease increases with age, but 23% of deaths are in persons less than 65 years. Figure 6. Ischemic heart disease death rates in Georgia and the United States, 1980-1999 Age-adjusted death rate per 100,000 population 350 300 US 250 200 150 GA 100 50 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 NOTE. The vertical dotted line indicates a change in coding systems used for cause of death. ICD-9 codes were used for 1980-1998; ICD-10 codes were used for 1999 deaths. Figure 7. Ischemic heart disease death rates in Georgia by race and sex, 1999 Age-adjusted death rate per 100,000 population 250 222.7 232.2 200 150 100 Black White 150.6 128.1 50 0 Males Females 7 STROKE MORTALITY IN GEORGIA Age-adjusted death rate per 100,000 population Age-adjusted death rate per 100,000 population Figure 8. Stroke death rates in Georgia and the United States by year, 1980-1999 140 GA 120 100 80 60 US 40 20 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 NOTE. The vertical dotted line indicates a change in coding systems used for cause of death. ICD-9 codes were used for 1980-1998; ICD-10 codes were used for 1999 deaths. Figure 9. Stroke death rates in Georgia by race and sex, 1999 120 105.9 100 80 66.1 60 40 20 0 Males Black White 82.2 65.8 Females Figure 10. Stroke deaths by type, Georgia, 1999 Subarachnoid hemorrhage 5% Sequelae 11% Other hemorrhage 17% Other, ill-defined 5% Occlusion 6% Acute, ill-defined 56% Stroke, technically known as a cerebrovascular accident, refers to an infarct (loss of blood supply due to a blocked artery) or hemorrhage in the brain. Of the 24,274 CVD deaths in Georgia in 1999, 4,277 (18%) were due to stroke. Age-adjusted death rates from stroke have decreased during the past two decades in both Georgia and the U.S. (Figure 8); however, since 1992, the rate of decline has slowed. In Georgia, the stroke death rate decreased an average of 4.4% per year from 1980 to 1992 but only 0.7% per year from 1992 to 1998. Age-adjusted stroke death rates in Georgia are consistently above the U.S. rate although the gap is narrowing, with Georgia's rate 32% above the U.S. rate in 1980 but only 16% above the U.S. rate in 1999. In Georgia, the stroke death rate decreased an average of 4.4% per year from 1980 to 1992 but only 0.7% per year from 1992 to 1998 Unlike ischemic heart disease deaths, for which sex differences are more striking than racial differences, age-adjusted stroke deaths are much higher for blacks than whites. In 1999, the age-adjusted stroke death rate for blacks was 1.4 times the rate for whites in Georgia. Reasons for the difference are not well understood but may include the higher prevalence of high blood pressure and decreased access to health care among blacks. Black males had a higher age-adjusted death rate from stroke than black females, but the rates for white males and white females were almost the same in 1999 (Figure 9). Only a small percentage of stroke deaths in Georgia are classified as hemorrhagic or ischemic on death certificates. Most are coded to ill-defined forms of stroke (Figure 10), making it difficult to quantify or monitor trends in hemorrhagic stroke and ischemic stroke. As for most other types of cardiovascular disease, the stroke mortality rate increases with age. Nonetheless, 18% of persons dying from stroke in Georgia in 1999 were less than 65 years. 8 hospitalizations for cardiovascular disease in Georgia In addition to the more than 24,000 Georgians dying from CVD each year, many more Georgians experience a heart attack, stroke, or other cardiovascular disease that is not fatal. For most of these CVD survivors, their lives are forever changed. Most will need to take medications for the rest of their lives, and some are left with permanent, severe disabilities such as the loss of speech or the inability to move an arm or leg.We can estimate part of the burden of non-fatal CVD in Georgia by examining hospitalizations. In 1999, of almost one million hospitalizations in Georgia, 14.1% were for CVD.There were 128,386 hospitalizations for CVD among Georgia residents, an average of five hospitalizations for every CVD death. Georgia residents spent a total of 635,927 days in the hospital because of CVD, and the charges for these admissions totaled more than $1.9 billion (Table 3).The average charge per CVD hospitalization was $15,394, and the average length of stay was five days. The major primary diagnoses for CVD hospitalizations were ischemic heart disease, stroke, and heart failure (Figure 11). Ischemic heart disease accounted for 46,566 hospitalizations with an average length of stay of four days and average hospital charges of $18,277 per stay. There were 23,513 hospitalizations for stroke with an average length of stay of six days and average hospital charges of $13,808 per stay. Heart failure accounted for 22,390 hospitalizations with an average length of stay of five days and average hospital charges of $10,276 per stay. Hospital charges are only part of the direct medical costs of CVD. Other direct costs include physician fees, office visit costs, and medications. Indirect costs associated with CVD include longterm care and rehabilitation, lost productivity and lost family resources, particularly for individuals who suffer permanent disability.These additional costs are greater than the hospital charges.The health and economic burden that CVD places on the health care system is profound, and it will continue to grow as our population ages. 9 MEDICAL PROCEDURES FOR CARDIOVASCULAR DISEASE IN GEORGIA A ccording to an annual survey by the Georgia Department of Community Health, there were 83,439 cardiac catheterizations performed in non-federal facilities in Georgia in 1999.5 Of these, 77% were for diagnostic purposes only and 23% were therapeutic in nature.5 The total number of cardiac catheterizations in Georgia increased 25% from 1995 to 1999 (Table 2). In 1999, there were 10,449 open heart surgeries performed in Georgia.5 The number of open heart surgeries performed has been relatively stable since 1995 (Table 2). Figure 11. Cardiovascular disease hospitalizations, Georgia residents, 1999 Hypertensive disease Atherosclerosis 7% 3% Heart failure 17% Ischemic heart disease 37% Other 18% Stroke 18% Table 2. Number of cardiac catheterizations and open heart surgeries in Georgia, 1995-1999 Year 1995 1996 1997 1998 1999 Cardiac catheterizations 66,752 72,071 74,150 79,644 83,439 Open heart surgeries 10,223 10,762 10,990 10,256 10,449 Source: Georgia Department of Community Health, Division of Health Planning CARDIOVASCULAR DISEASE STATISTICS BY COUNTY Tables 3 and 4 (pages 11-14) show for each county and public health district in Georgia the number of CVD deaths in 1999, the average annual age-adjusted mortality rate for CVD from 1995 to 1999, the number of ischemic heart disease deaths and the corresponding age-adjusted rate, and the number of stroke deaths and the corresponding age-adjusted rate. Average annual age-adjusted mortality rates were calculated for a 5-year period because counties with small populations had too few deaths to calculate a rate accurately for a shorter time period. Caution should be used when making comparisons among age-adjusted county death rates because counties with small populations are more likely to have wide variations in rates from year to year simply due to chance. The right-hand set of columns in Tables 3 and 4 shows the total charges for CVD hospitalizations in 1999, the number of hospitalizations for CVD in 1999, and the number of hospitalizations for ischemic heart disease, stroke, and congestive heart failure. Hospitalization data are based on county of residence, not location of hospital. Caution should be used when making comparisons among counties because Georgia residents hospitalized outside of Georgia are not included in the tables.This may lead to an underestimation of hospitalizations for residents of counties near large cities in neighboring states (e.g., counties bordering Chattanooga,TN, or Jacksonville, FL). Figure 12 (map) shows average annual age-adjusted CVD deaths rates by county during the period 1995 through 1999. Counties with the highest CVD death rates are clustered in the southeast region and along the state's western border. Figure 13 (map) shows average annual age-adjusted stroke death rates by county, with the highest rates in the southwest corner and in other counties scattered throughout the state. Figure 12. Cardiovascular disease death rates by county, Georgia, 1995-1999 Age-adjusted death rates Significantly above the state rate Not significantly different from the state rate Significantly below the state rate Figure 13. Stroke death rates by county, Georgia, 1995-1999 Age-adjusted death rates Significantly above the state rate Not significantly different from the state rate Significantly below the state rate 10 TABLE 3. Cardiovascular disease deaths, age-adjusted mortality rates, and hospitalizations by county, Georgia, 1995-1999 Georgia CVD No. 1999 24,274 AAMR 1995-99 DEATHS H O S P I TA L I Z AT I O N S IHD Stroke CVD No. AAMR No. AAMR Total Charges 1999 1995-99 1999 1995-99 1999 CVD IHD Stroke CHF No. No. No. No. 1999 1999 1999 1999 406.4 10,502 185.4 4,277 76.8 $1,976,409,081 128,386 46,566 23,513 22,390 Appling 69 471.5 25 Atkinson 27 678.7 7 Bacon 53 585.7 30 Baker 22 425.1 10 Baldwin 157 421.7 81 Banks 39 452.1 20 Barrow 114 380.6 43 Bartow 229 436.9 98 Ben Hill 97 478.3 50 Berrien 80 456.0 38 Bibb 662 456.2 306 Bleckley 51 408.0 20 Brantley 44 470.6 16 Brooks 79 454.7 30 Bryan 51 394.6 26 Bulloch 176 427.5 42 Burke 83 529.3 30 Butts 69 418.5 35 Calhoun 31 593.3 20 Camden 73 415.2 31 Candler 50 478.6 25 Carroll 287 433.9 141 Catoosa 172 387.6 105 Charlton 37 513.6 21 Chatham 838 384.7 371 Chattahoochee 14 655.8 9 Chattooga 116 489.4 70 Cherokee 311 418.9 115 Clarke 270 374.8 110 Clay 29 515.5 9 Clayton 483 432.3 222 Clinch 32 537.5 10 Cobb 1,125 376.5 435 Coffee 133 453.4 65 Colquitt 185 458.4 83 Columbia 171 346.8 83 Cook 78 485.0 40 Coweta 214 406.2 80 Crawford 39 366.1 24 Crisp 87 415.4 30 Dade 47 356.0 27 Dawson 32 356.6 13 Decatur 142 495.5 45 DeKalb 1,356 342.1 506 Dodge 95 483.8 53 Dooly 40 445.1 18 Dougherty 360 394.8 144 182.4 7 196.4 4 339.5 13 162.1 3 236.7 37 229.3 4 161.5 19 182.2 34 231.0 9 227.0 16 219.3 118 148.5 7 202.2 7 184.6 16 172.8 7 120.8 39 246.1 12 212.2 17 208.3 3 192.6 5 213.8 4 212.8 59 221.6 19 260.9 6 196.6 137 299.7 0 260.8 16 170.1 41 164.9 56 210.7 9 201.8 81 188.6 1 164.1 176 222.3 16 212.5 36 186.7 29 282.6 21 170.8 50 216.1 5 147.6 15 177.0 4 178.8 4 151.5 25 136.5 267 233.7 18 222.8 6 155.7 66 94.6 124.5 113.8 82.1 80.0 105.1 58.7 80.8 66.9 65.0 83.8 62.2 98.3 82.6 51.7 100.3 94.0 80.5 221.4 54.4 90.6 101.4 51.9 78.9 64.3 39.7 111.4 59.3 74.9 151.3 70.3 89.1 68.5 84.0 81.0 56..6 95.0 89.6 42.7 86.6 54.9 62.7 115.9 71.0 85.2 106.3 86.9 $6,210,746 $1,467,757 $2,180,489 $1,021,017 $14,723,124 $3,702,479 $13,240,698 $26,577,980 $6,517,328 $4,230,990 $77,566,013 $4,111,736 $3,594,423 $3,056,424 $8,014,315 $17,440,536 $5,772,425 $6,445,054 $1,671,405 $1,990,615 $3,810,100 $25,546,242 $4,337,817 $1,006,050 $71,876,888 $699,291 $13,827,188 $23,995,833 $21,452,529 $450,700 $45,787,512 $1,246,799 $103,208,283 $7,485,792 $7,848,568 $12,680,575 $3,930,834 $19,050,850 $2,348,115 $6,390,291 $796,295 $5,386,667 $3,266,229 $100,889,718 $8,200,677 $6,624,470 $28,743,477 372 130 221 63 876 270 838 1,458 510 432 4,228 321 274 349 349 952 361 427 157 227 254 1,782 292 115 3,882 43 707 1,550 1,291 36 2,868 120 6,341 707 711 669 442 1,213 136 586 73 315 440 6,379 651 506 1,766 151 28 84 15 359 119 370 664 189 154 1,769 154 110 103 130 347 87 163 24 71 80 672 97 27 1,079 16 299 733 416 12 1,180 33 2,726 201 189 269 129 453 66 189 26 132 108 1,897 284 190 458 60 24 35 17 150 51 126 203 71 90 690 54 40 75 61 188 89 90 37 27 47 391 61 16 812 5 113 260 268 7 455 19 1,067 127 160 127 88 247 24 128 12 50 89 1,320 89 92 343 46 27 56 13 156 37 119 163 107 62 783 49 43 91 67 134 82 56 51 36 44 249 55 32 772 11 120 193 182 8 487 22 641 145 148 91 89 198 16 99 16 62 105 1,142 115 102 368 11 Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery CVD No. 1999 209 68 12 81 105 99 43 74 200 457 209 84 2,172 98 15 243 155 98 67 695 132 396 45 117 71 117 35 255 279 33 155 53 66 76 46 40 81 60 12 209 33 110 29 21 315 50 59 94 28 97 43 118 39 91 74 34 AAMR 1995-99 392.0 496.9 539.7 402.8 421.1 471.5 433.1 299.8 353.8 446.3 397.4 458.0 393.9 347.9 342.1 345.2 438.4 439.9 468.8 306.7 394.3 393.7 441.7 431.9 377.8 379.2 435.0 375.4 408.0 423.3 462.6 419.6 513.5 435.8 450.4 418.2 399.2 406.6 519.9 487.2 301.7 414.6 500.0 389.8 431.8 361.5 429.2 405.5 496.8 391.4 563.9 486.9 437.0 449.9 445.5 458.1 DEATHS IHD No. AAMR 1999 1995-99 Stroke No. AAMR 1999 1995-99 H O S P I TA L I Z AT I O N S CVD Total Charges 1999 CVD IHD No. No. 1999 1999 Stroke No. 1999 88 220.0 32 56.8 $19,984,506 1,253 556 224 38 269.6 12 103.6 $1,016,531 109 14 23 3 249.4 3 92.7 $266,377 24 11 5 39 211.3 15 70.2 $7,818,013 404 138 85 50 228.2 25 82.1 $7,098,664 531 203 102 43 211.4 15 85.6 $9,332,419 648 215 109 13 181.0 19 145.3 $4,677,918 322 82 83 39 136.8 11 54.7 $7,595,775 526 227 94 89 167.0 36 60.6 $16,388,008 1,028 449 171 204 217.1 61 76.8 $49,431,519 2,417 912 392 97 195.3 31 66.2 $14,636,654 973 408 160 46 253.8 9 78.6 $8,207,081 634 248 113 941 175.6 379 72.3 $179,385,334 11,849 3,256 2,051 52 198.0 10 47.0 $7,049,209 522 214 89 2 96.3 2 92.8 $1,538,489 84 21 19 102 142.1 52 72.0 $17,023,591 1,473 383 234 72 220.0 33 86.1 $19,471,133 1,093 464 187 53 218.0 12 84.3 $2,873,354 345 93 67 27 180.6 7 83.4 $3,960,147 268 82 58 282 131.5 125 61.5 $81,863,140 4,892 2,261 788 63 194.3 22 76.2 $9,677,293 737 371 118 175 186.5 91 89.2 $32,562,731 2,187 855 402 5 93.7 11 75.6 $3,099,741 219 51 40 63 213.0 16 95.0 $11,417,550 632 241 134 25 146.7 13 58.8 $3,421,891 202 81 45 61 219.4 24 72.0 $6,368,886 509 202 83 10 138.5 7 97.1 $2,114,297 176 58 45 109 182.0 53 67.9 $26,901,493 1,655 743 285 104 185.3 48 69.0 $33,398,956 2,251 1,058 339 21 237.6 2 58.7 $2,041,983 206 60 34 89 214.5 25 87.0 $14,069,821 891 394 151 36 239.6 5 36.6 $3,769,601 258 87 46 37 261.3 5 62.5 $5,810,549 312 133 48 17 205.2 15 74.0 $7,377,671 421 106 104 27 234.8 13 128.6 $3,281,755 235 48 57 11 172.5 10 74.1 $2,233,237 165 59 29 42 192.4 15 67.2 $5,534,789 276 141 54 22 140.6 11 85.1 $4,922,430 356 144 70 6 205.1 3 79.0 $1,294,426 159 32 20 95 249.9 44 97.5 $16,681,786 1,075 443 161 10 131.3 6 76.6 $3,672,357 258 89 43 37 172.5 24 80.2 $8,733,711 440 146 77 11 236.9 5 106.2 $4,198,364 228 113 35 8 125.4 3 58.0 $1,903,787 109 33 15 120 194.2 61 89.3 $15,163,719 1,450 376 303 20 194.2 8 61.5 $3,983,426 349 151 62 19 127.2 15 88.7 $2,918,165 222 86 47 47 194.7 13 57.8 $10,329,323 628 227 119 12 218.8 2 91.4 $1,632,800 79 22 16 26 214.4 15 54.5 $9,141,692 489 190 99 19 239.1 4 96.3 $2,791,237 197 48 35 51 244.8 17 88.6 $5,944,104 447 141 95 16 206.4 2 70.1 $953,640 105 27 18 40 222.7 19 96.6 $4,650,226 384 111 73 47 258.6 11 70.9 $4,292,454 336 120 74 9 132.8 2 54.6 $2,265,477 154 62 23 CHF No. 1999 162 33 2 70 110 135 74 72 130 442 169 117 2,797 85 23 237 183 97 41 648 88 382 42 95 22 103 20 284 353 58 161 45 47 81 44 23 34 49 51 177 46 74 29 22 271 72 53 106 14 75 34 84 24 103 46 24 12 Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth 13 CVD No. AAMR 1999 1995-99 78 461.8 81 411.9 683 436.8 184 447.4 69 374.1 55 499.8 143 408.3 86 395.0 88 426.9 86 475.0 45 409.1 203 509.5 44 464.5 76 395.3 11 545.2 63 371.0 52 522.8 672 460.9 209 383.1 12 456.8 76 489.0 45 453.3 252 482.6 139 397.9 24 436.8 144 433.2 33 461.1 13 498.2 88 486.0 39 554.7 69 527.2 61 472.9 181 415.2 122 429.2 132 480.6 60 306.5 38 532.9 301 499.0 43 498.8 48 478.7 88 338.9 154 527.7 315 459.4 180 414.1 188 467.9 38 444.1 104 398.4 102 495.1 15 417.3 32 509.2 82 376.4 260 394.3 35 412.5 48 407.8 50 490.5 89 469.0 DEATHS IHD No. AAMR 1999 1995-99 43 267.6 41 193.6 339 212.2 79 189.6 34 180.6 15 176.1 54 184.9 42 186.5 19 139.5 35 184.4 19 185.7 96 232.3 25 275.8 38 216.5 3 91.5 27 146.2 19 180.5 334 233.0 94 161.2 6 226.3 29 236.1 14 186.3 91 204.0 49 134.6 7 199.9 62 193.7 14 206.1 5 165.0 37 250.4 24 268.0 34 248.6 24 207.5 61 153.8 48 215.7 31 103.5 24 135.2 6 115.7 102 211.6 25 240.8 20 194.5 40 174.3 63 217.5 163 242.9 107 250.4 70 192.9 12 88.3 33 160.2 47 193.8 7 169.6 15 175.3 41 181.9 125 171.8 12 185.1 24 192.2 24 234.8 48 228.9 Stroke No. AAMR 1999 1995-99 12 70.8 14 92.9 93 69.4 51 130.6 12 71.0 10 115.7 13 70.6 8 60.3 8 57.3 8 62.7 6 49.3 27 86.4 12 109.0 9 52.7 4 102.7 7 48.8 7 124.4 118 77.4 53 95.6 4 88.4 23 114.8 13 120.0 52 94.9 23 76.2 6 89.0 33 84.3 4 70.4 3 128.4 18 91.5 8 111.2 17 123.2 12 76.4 51 115.2 28 76.7 23 89.8 15 54.9 6 95.6 67 100.5 6 98.3 9 85.6 10 54.6 37 132.7 41 87.7 31 69.4 29 70.5 4 55.3 18 86.5 25 152.8 3 69.9 5 107.2 13 80.0 57 85.3 3 78.7 8 87.6 10 81.4 17 74.0 H O S P I TA L I Z AT I O N S CVD CVD IHD Stroke Total Charges No. No. No. 1999 1999 1999 1999 $4,789,737 290 107 59 $6,773,255 521 219 88 $50,658,462 3,191 972 666 $17,464,119 1,294 483 262 $5,974,725 376 116 83 $2,418,756 173 66 34 $10,442,821 645 282 114 $9,611,814 653 257 90 $6,856,913 380 179 48 $4,041,315 372 131 72 $3,977,278 285 102 63 $23,024,681 1,204 481 232 $4,342,234 333 154 67 $6,786,298 448 224 71 $349,652 26 9 4 $4,179,714 345 103 80 $1,920,150 153 28 36 $66,760,031 3,572 1,186 711 $15,492,970 958 383 185 $1,055,014 86 14 19 $6,968,170 415 141 97 $775,500 147 31 23 $19,311,458 1,307 470 277 $10,747,277 789 357 110 $1,717,670 132 17 43 $8,973,808 706 182 179 $3,151,974 149 45 29 $1,065,880 57 18 11 $6,990,447 428 130 85 $3,022,867 217 63 55 $7,559,067 550 228 75 $3,762,554 250 60 48 $7,928,631 848 257 190 $8,130,939 654 175 130 $9,680,149 611 211 117 $4,891,936 330 151 48 $2,736,337 156 61 23 $16,914,088 1,477 479 382 $2,572,745 193 84 26 $3,905,171 210 81 30 $6,536,733 507 231 75 $10,756,127 840 361 156 $10,722,991 807 255 171 $11,815,213 882 348 153 $1,267,701 989 341 154 $2,360,365 149 44 30 $6,964,189 423 169 63 $9,068,760 663 239 120 $710,419 46 12 16 $2,526,263 186 83 31 $7,373,867 502 214 72 $18,849,174 1,326 509 257 $3,729,448 247 99 38 $5,324,733 314 125 47 $5,526,675 298 144 46 $4,939,954 379 111 71 CHF No. 1999 37 83 688 225 70 24 75 117 44 62 52 190 44 57 3 60 39 540 144 21 66 37 200 107 36 143 28 12 86 41 114 61 190 139 137 54 20 225 21 48 84 145 169 139 184 31 53 115 7 22 91 227 45 61 37 85 TABLE 4. Cardiovascular disease deaths, age-adjusted mortality rates, and hospitalizations by health district, Georgia, 1995-1999 Georgia District 1-1: Northwest (Rome) District 1-2: North Georgia (Dalton) District 2: North (Gainesville) District 3-1: Cobb-Douglas District 3-2: Fulton District 3-3: Clayton District 3-4: East Metro (Lawrenceville) District 3-5: DeKalb District 4: LaGrange District 5-1: South Central (Dublin) District 5-2: North Central (Macon) District 6: East Central (Augusta) District 7: West Central (Columbus) District 8-1: South (Valdosta) District 8-2: Southwest (Albany) District 9-1: East (Savannah) District 9-2: Southeast (Waycross) District 9-3: Coastal (Brunswick) District 10: Northeast (Athens) CVD No. AAMR 1999 1995-99 24,274 406.4 1,954 440.0 DEATHS IHD No. AAMR 1999 1995-99 10,502 185.4 952 216.5 Stroke No. AAMR 1999 1995-99 H O S P I TA L I Z AT I O N S CVD CVD IHD Stroke CHF Total Charges No. No. No. No. 1999 1999 1999 1999 1999 4,277 76.8 $1,976,409,081 128,386 46,566 23,513 22,390 264 80.0 $170,049,975 9,328 3,721 1,619 1,508 912 388.5 391 168.8 141 67.9 $71,120,159 4,825 2,081 836 704 1,491 382.3 676 185.2 261 73.2 $118,254,744 8,447 3,542 1,424 1,426 1,334 2,172 483 1,088 377.8 393.9 432.3 337.1 523 171.7 941 175.6 222 201.8 455 143.8 208 66.5 $123,192,789 7,594 3,282 1,291 803 379 72.3 $179,385,334 11,849 3,256 2,051 2,797 81 70.3 $45,787,512 2,868 1,180 455 487 229 76.1 $114,820,229 7,144 3,127 1,235 1,017 1,356 1,990 804 342.1 426.8 473.7 506 136.5 812 191.5 361 214.9 267 71.0 $100,889,718 6,379 1,897 1,320 1,142 412 87.9 $158,271,429 10,993 4,235 2,272 1,692 161 91.0 $69,109,386 4,714 1,986 740 789 1,597 426.9 721 205.9 267 74.1 $162,803,816 9,736 4,167 1,567 1,631 1,463 437.8 643 209.4 262 79.4 $135,802,569 7,642 2,563 1,535 1,270 1,341 441.6 603 200.2 222 79.1 $93,697,624 6,380 1,938 1,387 1,315 871 448.7 381 214.9 165 81.0 $47,205,765 4,419 1,313 842 891 1,445 434.6 606 184.1 277 95.9 $73,123,443 5,962 1,587 1,202 1,361 919 385.1 410 197.5 152 64.9 $79,694,901 4,286 1,217 897 842 1,326 476.9 511 190.4 224 94.2 $85,979,531 6,842 2,328 1,295 1,254 541 370.2 223 157.6 95 67.4 $40,457,256 2,795 811 449 470 1,187 409.5 565 202.7 210 73.8 $95,149,613 6,168 2,329 1,153 989 ABBREVIATIONS AAMR = Age-adjusted mortality rate CHF = Congestive heart failure CVD = Cardiovascular disease IHD = Ischemic heart disease Additional abbreviations can be found on page 20. 14 Cardiovascular disease RISK FACTORS Some CVD risk factors are "modifiable," meaning that individuals can change their behavior to slow, or even reverse, the process of arterial blockage and decrease their risk of having a heart attack or stroke. Modifiable risk factors include smoking, high blood pressure, high blood cholesterol level, overweight or obesity, lack of regular physical activity, and poor diet. Some CVD risk factors cannot be changed, such as old age, male sex, and a family history of heart attacks at a young age. Individuals with unmodifiable risk factors should be particularly diligent in eliminating modifiable risk factors.The leveling off of the Georgia CVD death rate may be related to a recent increase in prevalence in CVD risk factors in Georgia. SMOKING The percentage of Georgians who currently smoke declined from 31% in 1984 to 19% in 1992. Since then, the percentage of adults who smoke has been consistently higher than 20% (Figure 14). In 1999, 24 percent of Georgia adults reported that they currently smoke cigarettes. Lowering smoking rates is a public health priority. In addition to its well-known association with cancer, smoking is a major CVD risk factor. In fact, each year smoking causes more deaths from heart attacks than from cancer.6 The good news is that giving up smoking quickly reduces the chance of developing CVD.7 It is also important to prevent people, especially young people, from starting to smoke. Most smokers begin using tobacco before their eighteenth birthday, suggesting that if adolescents are kept tobacco-free, most will never start smoking.8 Percentage Figure 14. Percentage of Georgians reporting current smoking, 1984-1999 35 30 25 20 15 10 5 0 1984 1985 1986 1987 1988 1989 1990 1991 1992 19931994 1995 1996 1997 1998 1999 One of every four adults in Georgia currently smokes, over half are overweight or obese, and three of every four do not get regular physical activity. Figure 15. Percentage of Georgians reporting high blood pressure and percentage reporting high blood cholesterol, 1984-1999 Percentage 35 30 High cholesterol 25 20 15 High blood pressure 10 5 0 1984 1985 19861987 198819891990 19911992 19931994 199519961997 1998 1999 15 Percentage Figure 16. Percentage of Georgians reporting no regular physical activity and percentage overweight or obese, 1984-1999 No regular physical activity 90 80 70 60 50 40 30 Overweight or obese 20 10 0 1984 1985 1986 1987 1988 1989 1990 1991 1992 19931994 1995 1996 1997 1998 1999 Figure 17. Daily servings of fruits and vegetables consumed by Georgians, 1998 5 servings 21% <1 serving 5% 3-4 servings 37% 1-2 servings 37% Excess body fat increases risk for heart disease and stroke. Excess weight can lead to high blood pressure, high cholesterol, or diabetes, all of which increase the risk for CVD. HIGH BLOOD PRESSURE High blood pressure is a major risk factor for both heart disease and stroke.The percentage of Georgians who report having been told they have high blood pressure has remained between 19% and 26% since 1984 (Figure 15).The percentage of Georgians with high blood pressure whose blood pressure is under control is not known. Nationally, about three quarters of people with high blood pressure know they have it, just over half are being treated, and just over one fourth are under control.9 Some people can control their high blood pressure by losing weight and engaging in regular physical activity. For those who are unable to decrease their blood pressure by lifestyle modification alone, medications prescribed by a physician can often control high blood pressure successfully. HIGH CHOLESTEROL When there is too much cholesterol in blood, the excess can become trapped in the artery walls. Cholesterol buildup happens very slowly, but over time causes most heart attacks. Cholesterol is transported to and from cells by lipoproteins. Low-density lipoprotein (LDL), the "bad cholesterol," clogs the arteries to the heart; a high level of LDL increases the risk for heart disease. High-density lipoprotein (HDL), the "good cholesterol," carries cholesterol away from the heart and other parts of the body; a high level of HDL decreases the risk for heart disease. A high total cholesterol level increases the risk for heart disease. Lowering high total blood cholesterol levels can decrease the likelihood of death from heart disease.10 The percentage of Georgia adults who report ever having had their blood cholesterol level checked increased from 53% in 1987 to 78% in 1999. Of persons who had been checked, the percentage told they have high cholesterol increased from 15% in 1987 to 29% in 1999 (Figure 16). It is not known if the increase in the percentage of persons reporting high cholesterol represents a true increase in cholesterol levels among Georgians. Nationally, mean cholesterol levels decreased during the period 1972 to 1990.11 Many people can control their cholesterol level by modifying their diet. For those who cannot, medication can lower blood cholesterol levels. In adults, a total cholesterol level of 200 mg/dL or higher is considered high risk; LDL levels >130 mg/dL or HDL levels <40mg/dL are also considered high risk.9 The National Institutes of Health recommend that all adults get a fasting lipoprotein profile (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides) every five years.10 16 PHYSICAL INACTIVITY AND BEING OVERWEIGHT Regular moderate or vigorous physical activity can reduce the risk for CVD.12 Many Georgians are not physically active on a regular basis (Figure 16). Approximately 76% of Georgia adults do not get regular physical activity (at least 30 minutes per day of moderate-intensity activity, such as walking at a brisk pace, on five or more days a week). Additional information about the physical activity patterns of Georgians, the costs of inactivity, and suggestions for future actions can be found in the 2001 Georgia Physical Activity Report, published by the Georgia Department of Human Resources and the American Heart Association. Overweight and obese adults are at increased risk for CVD.13 In both Georgia and the U.S., there has been a steady increase in the percentage of overweight (body mass index 25.0 29.9) and obese adults (body mass index 30.0; see appendix for details). From 1984 to 1999, the percentage of overweight and obese Georgians increased from 37% to 58%.The prevalence of overweight or obese adults in Georgia is higher than the median of 56% for the U.S. See Table 5 for body mass index corresponding to normal weight, overweight, and obese. In 1998, only 19% of overweight and obese adults in Georgia reported that a health care professional had advised them to lose weight within the past 12 months. Losing weight and being physically active on a regular basis can improve blood pressure and cholesterol levels and can decrease the chance of developing diabetes, another risk factor for heart disease.12, 13 DIET Eating five or more servings of fruits and vegetables per day can help to prevent heart disease, cancer, and other chronic conditions. In 1998, only 21% of Georgians reported that they ate at least five servings of fruits and vegetables per day (Figure 17, page 16). DIABETES Persons with diabetes have two to three times the risk for death from cardiovascular disease as persons who do not have diabetes.14 The prevalence of diabetes has increased nationwide during the past decade in adults.15 Among children, prevalence of diabetes has increased, most likely because of an increase in type 2 diabetes, which is associated with obesity.16 In Georgia, the prevalence of diabetes among adults increased from 4% in 1993 to 6% in 1999; no data are available for children.Type 2 diabetes can be prevented by maintaining normal body weight and staying physically active. Persons with diabetes can prevent complications by keeping their blood sugar as close to normal as possible, refraining from smoking, eating a healthy diet, getting regular physical activity, and maintaining normal blood pressure. PREVIOUS CARDIOVASCULAR DISEASE In 1998 and 1999, approximately 8% of Georgia adults reported having had a heart attack, ischemic heart disease, or a stroke. Although these persons cannot change the past, they can take steps to prevent recurrences.The American Heart Association recommends consideration of the use of aspirin for persons who have had a heart attack, unstable angina, ischemic stroke, or transient ischemic attack. Of Georgians reporting a history of heart attack, ischemic heart disease, or stroke, 54% reported taking aspirin every day. For certain types of heart conditions, other medications may be needed to reduce the risk of recurrence. From 1984 to 1999, the percentage of overweight and obese Georgians increased from 37% to 58%. 17 TABLE 5. Body Mass Index Table NORMAL OVERWEIGHT OBESE BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 HEIGHT (inches) BODY WEIGHT (pounds) 4'10" 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 4'11" 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 5' 97 102 107 112 118 123 128 133 138 142 148 153 158 163 168 174 179 5'1" 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 5'2" 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 5'3" 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 5'4" 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 5'5" 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 5'6" 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 5'7" 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 5'8" 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 5'9" 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 5'10" 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 5'11" 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 6' 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 6'1" 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 6'2" 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 6'3" 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 6'4" 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 Source: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults:The Evidence Report. NIH Publication No. 98-4083 To calculate your Body Mass Index (BMI) find your height in the first column and scan across to find your weight.The number at top of the column is your BMI. Normal ranges from 19 to 24, overweight from 25 to 29, and obese 30 or above. 18 Conclusion This report summarizes the most recent information available on cardiovascular disease deaths and reducing blood cholesterol, engaging in regular physical activity, and eating a healthy diet. hospitalizations in Georgia.The most important finding of this report is the slowing of the decline in CVD death Sustained behavioral changes are often difficult to make, rates during the 1990s. It is not even for highly motivated individuals. possible to explain conclusively the reasons for the change in CVD death It is crucial to involve entire Therefore, it is critical that entire communities make policy and rate trends, but two factors are probably important. First, there has communities in changing environmental changes that make it easier for individuals to change been an increase in the prevalence of risk factors for CVD, such as smoking societal norms of behavior. their behavior. Community leaders and parents can act as role models. and overweight, that put Georgians at risk for a heart attack or stroke. Community leaders Additionally, local environments, such as schools and workplaces, Second, owing to advances in medical care, the number of Georgians and parents can act as role can be changed to facilitate healthy behaviors. Environmental changes who have already had a heart attack or stroke is growing.These models. Local environments, include creation of more walkable communities and replacement of cardiovascular disease survivors are at particularly high risk for dying such as schools, neighborhoods, soda vending machines with those offering juice and water. from CVD, and thus contribute to a growing number of CVD deaths. and workplaces, Much of the death and disability from The practical implications of these can be changed to facilitate CVD in Georgia is preventable. If we focus attention on realistic ways of findings are clear. Because most heart attacks and strokes result from a healthy behaviors. reducing risk, we can renew the decline in CVD death rates that process of arterial blockage that Georgia has experienced in much begins at an early age, a greater effort should be made to of the past two decades. Georgians can work together reduce the prevalence of risk factors among all Georgians, to reduce the number of individuals who suffer and die including children and adolescents. Reducing CVD risk from cardiovascular disease by advocating for healthier factors involves not smoking, controlling high blood pressure, communities and following treatment recommendations. THE PAUL COVERDELL NATIONAL ACUTE STROKE REGISTRY Senator Paul C. Coverdell (1939-2000) Emory University, in collaboration with the Georgia Medical Care Foundation, received a one-year grant from CDC to participate in "The Paul Coverdell National Acute Stroke Registry." Georgia is one of four states participating in the project. The objective of the stroke registry is to improve the quality of care for patients with acute stroke. The project involves collecting information on all persons admitted to participating hospitals with a diagnosis of stroke. The data will be used to identify strengths in patient management and opportunities for improved care so as to provide education for clinicians and multidisciplinary teams. The registry gives Georgia the opportunity to impact national health care policy and at the same time improve stroke management in our communities. Over 40 acute care hospitals in the state will be participating in the project. Dr. Michael Frankel of the Emory University School of Medicine is the principal investigator for the project. Senator Paul C. Coverdell faithfully served the citizens of Georgia as a soldier, legislator, Peace Corps Director, and United States Senator, until a massive stroke took his life on July 18, 2000. 19 Reduce Your Risk FOR HEART DISEASE AND STROKE To reduce your risk of heart disease, we recommend that you do the following : Don't smoke cigarettes.Tobacco use is the number one preventable cause of heart disease in the U.S.Tobacco makes your blood clot more easily, stiffens the walls of your arteries, and deprives your heart of needed oxygen.The message is simple: if you use tobacco, stop; if you don't use tobacco, don't start. Stay active. Moderate physical activity (such as walking or yard work) for a total of 30 minutes a day on most days of the week helps keep your weight down, allows your body to get rid of "bad" cholesterol, and can help keep your blood pressure under control. Recent research shows that you don't have to do your daily allotment of physical activity all at once.Ten or fifteen minutes at a time will be enough, as long as it adds up to at least 30 minutes most days of the week. Just make physical activity a regular part of your life. Eat less fat. Dietary fats, especially animal fats, pose another big threat to your heart. The National Institutes of Health recommend that you keep your fat intake to 25% to 35% of total calories and consume no more than 7% of your total calories from animal or saturated fats. Use the FDA "Nutrition Facts" on the label of all processed foods to help you cut down on your fat intake.The American Heart Association also has free dietary recommendations. Check your blood pressure. Uncontrolled high blood pressure is a leading risk factor for stroke, which is like a heart attack, only in the brain. Stroke is a leading cause of disability among adults and the third leading cause of death in Georgia. If your blood pressure is normal, get it checked at least every two years. If your blood pressure is 130/85 or over, consult a physician. He or she can help you get it under control. Check your cholesterol level. If your cholesterol is normal (total cholesterol less than 200), get it checked every five years. If it is high, see your doctor about getting it under control. Eating foods low in saturated fat and cholesterol, such as most fruits and vegetables, and staying physically active are two easy ways to keep your cholesterol low. Recognize and treat diabetes. Having diabetes (high blood sugar) can seriously increase your risk of stroke and heart disease. If you have diabetes, you can prevent or delay heart and blood vessel disease by controlling your weight, cholesterol, and blood pressure. In addition, never stop taking your diabetes medications without consulting your doctor first. Always consult your doctor if you have questions about your medications for diabetes and high blood pressure. Know your family's heart history. Heart disease often runs in families. If your family has a history of early heart disease, you may be at increased risk. If so, do not despair. You can readily reduce that risk by following the above steps. Your family will thank you for it. 20 References 1American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas,TX: American Heart Association, 2000. 2Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. Deaths: final data for 1999. National Vital Statistics Reports; vol 49 no 8. Hyattsville, MD: National Center for Health Statistics, 2001. 3Strong JP, Malcom GT, McMahan CA, et al. Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA 1999;281:727-735. 4Sternby NH, Fernandez-Britto JE, Nordet P. Pathobiological determinants of atherosclerosis in youth (PBDAY Study), 1986-96. Bull World Health Organ 1999;77:250-257. 5Specialized cardiovascular services component plan. Atlanta, GA: Health Strategies Council and Department of Community Health, 2001. 6CDC. Smoking attributable mortality and years of potential life lost United States, 1984. MMWR 1997;46:444-451. 7U.S. Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. 8U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. 9Burt VL, Cutler JA, Higgins M, et al.Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population: data from the Health Examination Surveys, 1960 to 1991. Hypertension 1995;26:60-69. 10Third report of the National Cholesterol Education Program Expert Panel on detection evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). 11Ernst ND, Sempos CT, Briefel RR, Clark MB. Consistency between US dietary fat intake and serum total cholesterol concentrations: the National Health and Nutrition Examination Surveys. Am J Clin Nutr 1997;66(Suppl):965S972S. 12U.S. Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 13National Institutes of Health Consensus Development Panel on Health Implications of Obesity. Ann Intern Med 1985;103:1073-1077. 14CDC.The prevention and treatment of complications of diabetes mellitus: a guide for primary care practitioners. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1991. 15Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: 1990-1998. Diabetes Care 2000;23:1278-1283. 16American Diabetes Association.Type 2 diabetes in children and adolescents. Diabetes Care 2000;23:381-389. Appendix: METHODS, GLOSSARY, AND ABBREVIATIONS METHODS Age-adjusted mortality rates for the U.S. and Georgia from 1980 through 1998 were obtained via WONDER at http://wonder.cdc.gov from the compressed mortality file compiled by the National Center for Health Statistics, CDC.The following ICD-9 codes were used: CVD, 390-448; ischemic heart disease, 410-414; and stroke, 430-438. The year 2000 projected population was used as the standard population. Age-adjusted mortality rates for Georgia in 1999 were based on death certificate data provided by the Vital Statistics Branch and Office of Health Information and Policy of the Georgia Division of Public Health.The following ICD-10 codes were used for CVD: CVD, I00-78; ischemic heart disease, I20-25; stroke, I60-69; hypertensive disease, I11, I13; other CVD, CVD codes not already categorized. ICD-10 codes for stroke included subarachnoid hemorrhage, I60; other intracerebral and intracranial hemorrhage, I61-62; occlusion, I63; acute ill-defined, I64; other ill-defined, I67; sequelae, I69. ICD-10 codes for non-CVD causes of death included cancer, C00C97; chronic respiratory disease, J40-J47; injuries,V01-X59,Y85-86; diabetes, E10-14; kidney disease, N00-07, N17-19, N25-27; influenza and pneumonia, J10-18; other, all disease codes not already categorized. Age-adjusted death rates for Georgia were calculated using the direct method with population estimates from the U.S. Bureau of the Census (release date: August 30, 2000) and the U.S. 2000 projected population as the standard. Age-adjusted death rates for the U.S. in 1999 were obtained from the National Vital Statistics Report,Vol 49, No. 8, September 21, 2001. The average annual percentage change in age-adjusted death rates represents the average of the relative change between each pair of consecutive years. Data on hospitalizations at acute care hospitals in Georgia were provided by the Office of Health Information and Policy after compilation by the Georgia Hospital Association. Analyses were restricted to Georgia residents.The following ICD-9 codes were used for principal diagnosis: CVD, 390-448; ischemic heart disease, 410-414; stroke, 430-438; heart failure, 428; hypertensive disease, 401-404; atherosclerosis, 440. Data on cardiac catheterizations and open heart surgeries were obtained from annual surveys of Georgia hospitals conducted by the Division of Health Planning of the Georgia Department of Community Health. Age-adjusted mortality rates for counties and districts were calculated using data from death certificates provided by Vital Statistics Branch and Office of Health Information and Policy. The number of deaths for 1999 was determined using the ICD-10 codes above (CVD, I00-78; ischemic heart disease, I20-25; stroke, I60-69).The number of deaths for 1995-1998 was determined using ICD-9 codes that correspond to the new ICD-10 codes (CVD, 390-434,436-448; ischemic heart disease 410-414,429.2; stroke, 430-434,436-438).The number of 21 deaths for 1995-1998 was multiplied by the "comparability ratio" provided by NCHS (National Vital Statistics Reports, Vol 49, No. 3) for CVD (0.9981), ischemic heart disease (0.9990), and stroke (1.0588), respectively, before calculating age-adjusted mortality rates. The "comparability ratio" compensates for the change in coding systems. Ageadjusted mortality rates were calculated using county population estimates from the U.S. Bureau of Census (release date: August 30, 2000) and the year 2000 projected population as the standard. The z-test was used to compare county rates to the state rate with significance at p<0.05.The source of the formula for the z-test and the standard error for an age-adjusted rate was the National Center for Health Statistics, National Vital Statistics Report, volume 48, number 11, July 24, 2000, page 104.This formula was not adjusted to reflect the use of comparability ratios for four years (1995-1998) of the five-year period of observation (1995-1999), given that no published formulas exist for such a situation; we assume that the increase in variability from use of comparability ratios is negligible given the small values of the relative standard errors of the comparability ratios. Data on risk factors were obtained from the Georgia Behavioral Risk Factor Surveillance System, a telephone survey conducted annually with a sample of adults aged 18 years and older.The sample is weighted so that it reflects the total adult population of the state. CVD risk factors assessed by the BRFSS include the following: Current smoker: defined as someone who has smoked at least 100 cigarettes his/her lifetime and smokes now High blood pressure: defined as ever having been told by a doctor, nurse, or health professional that your blood pressure was high High cholesterol: defined as ever having been told by a doctor or health professional that your blood cholesterol level was high Regular physical activity: defined as at least 30 minutes of moderate intensity physical activity five or more days a week or at least 20 minutes of vigorous physical activity three or more days a week Overweight: defined as a body mass index [BMI] from 25.0 - 29.9 kilograms per meters squared. BMI equals weight in kilograms divided by height in meters squared. Using weight in pounds and height in inches, BMI equals 705 times weight divided by height squared Obese: defined as a body mass index [BMI] 30.0 kilograms per meter squared Daily servings of fruits and vegetables: number of servings of fruit, fruit juice, green salad, potatoes, carrots, and other vegetables consumed per day based on reports of consumption during the past day, week, month, or year Diabetes: defined as ever having been told by a doctor that you have diabetes Previous cardiovascular disease: defined as ever having been told by a doctor that you had a heart attack or myocardial infarction, angina or coronary heart disease, or a stroke G L O S S A RY Age-adjusted death rate: a rate calculated based on a standard age distribution to enable comparison of rates in populations with different age structures Angina: pain or discomfort in the chest that occurs when the heart does not receive enough blood Atherosclerosis: deposits of cholesterol and other substances in the walls of arteries Cardiovascular disease: includes a wide variety of diseases of the heart and blood vessels, including ischemic heart disease (heart attacks), high blood pressure, stroke, and hypertensive heart disease Cholesterol: fatty substance in blood that gets deposited in blood vessel walls, causing atherosclerosis, when blood cholesterol levels are high Diabetes: a chronic disorder of metabolism affecting the way the body uses digested food for growth and energy HDL (high-density lipoprotein): carries cholesterol away from other parts of the body back to the liver for removal from the body Heart attack (also known as myocardial infarction): death or damage to the heart muscle caused by an insufficient supply of blood due to blockage of one or more coronary arteries Heart failure: condition in which the heart cannot pump enough blood to meet the body's needs Hospital charges: a hospital's full established rates, which do not necessarily reflect costs or reimbursement Ischemic heart disease (also known as coronary heart disease): includes heart attacks and related problems caused by a narrowing of the coronary arteries LDL (low-density lipoprotein): contains most of the cholesterol in the blood and carries it to tissues and organs via arteries; it is the main source of damaging buildup and blockage in the arteries Prevalence: the percentage of a population that has a disease or a risk factor at a given time Risk factor: a habit, characteristic, or finding on clinical examination that is associated with an increased probability of a disease Stroke: occurs when blood vessels to the brain burst or become clogged by a blood clot or some other particle resulting in lack of blood flow and oxygen to the brain and death of nerve cells A B B R E V I AT I O N S AAMR = Age-adjusted mortality rate BMI = Body Mass Index CDC = Centers for Disease Control and Prevention CHF = Congestive heart failure CVD = Cardiovascular disease HDL = High-density lipoprotein IHD = Ischemic heart disease ICD-9 = The International Classification of Diseases, 9th Revision ICD-10 = The International Classification of Diseases, 10th Revision LDL = Low-density lipoprotein 22 Georgia Department of Human Resources Division of Public Health, 16th Floor Cardiovascular Health Initiative 2 Peachtree Street, NW Atlanta, GA 30303 http://health.state.ga.us