Public Policy Approaches to the Prevention of Heart Disease and Stroke

studying the causes of human disease have long recognized the important roles of social, economic, and environmental factors.Engel's 1 biopsychosocial model emphasizes the importance of a hierarchy of systems from molecules to cells, to individuals and families, to societies, and to cultures in the causation of disease and its sequelae.Although specific diseases may vary in the contributions from each system, it is very clear that social and environmental factors contribute strongly to the risk of heart disease and stroke.Blackburn 2 provides an extensive compendium of evidence for a significant sociocultural contribution to the cause of the major cardiovascular diseases and the need for intervention at community and societal levels.Such evidence led Rose et al 3 to "seek a general change in behavioral norms and in the circumstances which facilitate their adoption."Many of the interventions in clinical medicine constitute the "high-risk approach," namely the clinical identification of individuals in that portion of the population at highest risk and their intensive treatment through behavioral or pharmacological means.For example, the detection and treatment of high blood cholesterol according to the Adult Treatment Panel guidelines seek to intensely treat the upper tail of the population distribution to move those high-risk individuals to more moderate levels of risk (Figure 1A). 4 American Heart Association guidelines for the primary and secondary prevention of heart disease and stroke largely use the high-risk approach. 5,6In contrast, the population approach to cholesterol reduction seeks to shift the entire curve to a lower risk level through population-wide changes in diet, exercise, and weight management (Figure 1B). 4 Both approaches are necessary, although analyses of the 20th century decline in coronary disease mortality suggest that the majority of the decline could be attributable to lifestyle changes in the American diet and the use of tobacco. 7,8For these reasons, the 2003 AHA guidelines for preventing heart disease and stroke at the community level 9 have been added to complement clinical guidelines for the treatment of individuals.The Public Health Action Plan to Prevent Heart Disease and Stroke (2003) includes policy and environmental changes affecting the entire US population as a means to change adverse behavioral patterns as the first goal of a comprehensive public health strategy to prevent heart disease and stroke. 10Indeed, recent considerations of the 2010 Affordable Care Act (US Healthcare Reform Legislation) emphasize the need for population-wide change outside the healthcare system, 11 citing estimates that only 10% to 15% of preventable deaths in the United States are affected by medical care. 12his contribution to the Recent Advances in Preventive Cardiology and Lifestyle Medicine series focuses on interventions that facilitate population-wide cardiovascular health through public policy, environmental change, and legislation.Although policy and legislation may have impacts on other important public health activities such as surveillance, public health education, and individual preventive health services, this review is limited to policy interventions that result in changes in the physical, economic, and social contexts that affect population-wide risk for heart disease and stroke.